Human monoclonal antibodies to the thyrotropin receptor which act as antagonists

ABSTRACT

The invention provides an isolated antibody for the TSHR which is an antagonist of TSH. The invention also relates to methods of using antibodies of the invention.

This application is the National Phase filing of International Application No. PCT/GB2008/000518, filed Feb. 14, 2008, which claims priority to Great Britain Patent Application No. GB 0702990.3, filed Feb. 15, 2007, to Great Britain Patent Application No. GB 0714036.1, filed Jul. 18, 2007, and to U.S. Provisional Patent Application No. 60/901,332, filed Feb. 15, 2007.

FIELD OF THE INVENTION

The present invention relates to antibodies which are reactive with the thyrotropin (TSH) receptor (TSHR), and in particular, though not exclusively, to antibodies which bind to the TSHR and which can block TSHR stimulation by TSH- or TSHR-stimulating antibodies.

BACKGROUND

Thyrotropin, or thyroid stimulating hormone (TSH), is a pituitary hormone that regulates thyroid function via the TSHR (Szkudlinski M W, Fremont V, Ronin C, Weintraub B D 2002 Thyroid-stimulating hormone and TSHR structure-function relationships. Physiological Reviews 82: 473-502). The TSHR is a G-protein coupled receptor and is composed of three domains:—a leucine rich domain (LRD), a cleavage domain (CD) and a transmembrane domain (TMD) (Nunez Miguel R, Sanders J, Jeffreys J, Depraetere H, Evans M, Richards T, Blundell T L, Rees Smith B, Furmaniak J 2004 Analysis of the thyrotropin receptor-thyrotropin interaction by comparative modelling. Thyroid 14: 991-1011). Binding of TSH to the TSHR triggers receptor signalling which leads to stimulation of formation and release of thyroid hormones; thyroxine (T4) and tri-iodothyronine (T3). A negative feedback mechanism involving the levels of T4 and T3 in the circulation controls the release of TSH from the pituitary (and thyrotropin releasing hormone secreted by the hypothalamus) that in turn controls thyroid stimulation and the levels of thyroid hormones in serum.

It is well documented in the art that some patients with autoimmune thyroid disease (AITD) have autoantibodies reactive with the TSHR (Rees Smith B, McLachlan S M, Furmaniak J 1988 Autoantibodies to the thyrotropin receptor. Endocrine Reviews 9: 106-121). In a majority of cases, these autoantibodies bind to the TSHR and mimic the actions of TSH thereby stimulating the thyroid to produce high levels of T4 and T3. These autoantibodies are described as thyroid stimulating autoantibodies or TSHR autoantibodies (TRAbs) with stimulating activity or TSH agonist activity. The physiological feedback mechanism of thyroid function control mentioned above is not effective in the presence of such thyroid stimulating autoantibodies and patients present with symptoms of thyroid hyperactivity or thyrotoxicosis (excess of thyroid hormones in serum). This condition is known as Graves' disease. In some patients, TRAbs with stimulating activity are thought to be responsible for interaction with TSHRs in retro-orbital tissues and to contribute to the eye signs of Graves' disease. A human monoclonal autoantibody which acts as a powerful thyroid stimulator (hMAb TSHR1) has been described in detail in patent application WO2004/050708A2.

In contrast in some patients with AITD, autoantibodies bind to the TSHR, prevent TSH from binding to the receptor but do not have the ability to stimulate the TSHR. These types of autoantibody are known as TRAbs with blocking activity or TSH antagonist activity, and patients who have blocking TRAbs in their serum may present with symptoms of an under-active thyroid (hypothyroidism) (Rees Smith B, McLachlan S M, Furmaniak J 1988 Autoantibodies to the thyrotropin receptor. Endocrine Reviews 9: 106-121). In particular, TRAbs with blocking activity when present in serum of pregnant women cross the placenta and may block foetal thyroid TSHRs leading to neonatal hypothyroidism and serious consequences for development. Furthermore, TRAbs with blocking activity can be found in breast milk of affected mothers and this may contribute further to clinical hypothyroidism in the baby. To date human monoclonal autoantibodies to the TSHR with TSH antagonist activity have not been available. Consequently, detailed studies of how this type of autoantibody interacts with the TSHR, and how their interactions with the TSHR compare with those of stimulating type of autoantibodies (such as M22) and with TSH, have been limited.

Human chorionic gonadotropin is a hormone produced during pregnancy which has mild thyroid stimulating effects.

Characterisation of the properties of TRAbs with stimulating or blocking activities is of critical importance in studies which aim to improve the diagnosis and management of diseases associated with an autoimmune response to the TSHR. The invention described in patent application WO2004/050708A2 provides details about the properties of a human monoclonal autoantibody with powerful stimulating activity and its interaction with the TSHR. Furthermore, patent application WO2006/016121A discloses a mutated TSHR preparation including at least one point mutation which can be used in the differential screening and identification of patient serum stimulating TSHR autoantibodies, patient serum blocking TSHR autoantibodies and TSH in a sample of body fluid from a patient being screened. Patent application WO2004/050708A2 also describes a mouse monoclonal antibody (9D33) with TSHR blocking activity. 9D33 binds to the TSHR with high affinity (2×10¹⁰ L/mol) and is an effective antagonist of TSH, hMAb TSHR1 (M22) and patient serum TRAbs with stimulating or blocking activities (patent application WO2004/050708A2 and Sanders J, Allen F, Jeffreys J, Bolton J, Richards T, Depraetere H, Nakatake N, Evans M, Kiddie A, Premawardhana L D, Chirgadze D Y, Miguel R N, Blundell T L, Furmaniak J, Rees Smith B 2005 Characteristics of a monoclonal antibody to the thyrotropin receptor that acts as a powerful thyroid-stimulating autoantibody antagonist. Thyroid 15: 672-682). Although the mouse monoclonal antibody 9D33 shows at least some of the characteristics of patient serum TRAbs with blocking activity, it is a mouse antibody generated by immunisation of an experimental animal with the TSHR and as such may not be truly representative of TSHR autoantibodies generated in the process of an autoimmune response to the TSHR in humans. As a mouse monoclonal antibody, 9D33 would need to be humanised for in vivo applications in humans. This may be disadvantageous in view of the expense and complication involved in the humanisation process.

The present invention results from the production and properties of a human monoclonal autoantibody (5C9) to the TSHR that is an effective antagonist of TSH and of stimulating TRAbs in patient sera. 5C9 has been isolated from the peripheral lymphocytes of a patient with hypothyroidism and high levels of TSHR autoantibodies. The lymphocytes were immortalised by infection with Epstein Barr virus (EBV) and positive clones fused with a mouse/human cell line to generate a stable clone. IgG was purified from supernatants of clone cultures and the ability of 5C9 IgG to bind to the TSHR and influence TSHR activity was assessed. In particular, the ability of 5C9 to inhibit TSH binding to the TSHR, and to inhibit cyclic AMP stimulating activity of TSH was studied. Furthermore, the ability of 5C9 to inhibit binding of stimulating or blocking patient serum TRAbs to the TSHR and to inhibit their biological activity was also assessed. In addition, the use of 5C9 in assays for TSHR antibodies, TSH and related compounds was investigated. Variable region (V region) genes of the heavy (HC) and light chains (LC) of 5C9 were sequenced and the complementarity determining regions (CDRs) assigned.

SUMMARY OF THE INVENTION

According to a first aspect of the invention there is provided an isolated human antibody for the TSHR which is an antagonist of TSH.

According to second aspect of the invention there is provided an isolated humanised antibody for the TSHR which is an antagonist of TSH.

An antibody according to either the first or second aspect of the invention is “an antibody according to the invention”.

An antibody according to the invention may be an antagonist of thyroid stimulating antibodies.

An antibody according to the invention may have the TSH antagonist characteristics of patient serum TSHR autoantibodies which are TSH antagonists.

An antibody according to the invention may be an antagonist of TSH and an antagonist of thyroid stimulating antibodies.

An antibody according to the invention may have the antagonistic characteristics of patient serum TSHR autoantibodies which are antagonists of thyroid stimulating antibodies.

An antibody according to the invention may be an inhibitor of binding to TSHR or a portion thereof by TSH, by M22, or antibodies with stimulating activity or antibodies with blocking activity to the TSHR. A TSHR portion may include the LRD or a substantial portion thereof. Preferably, an antibody which prevents such binding.

An antibody according to the invention may be a monoclonal or recombinant antibody, or comprise or consist of a fragment thereof which is an antagonist of TSH. An antibody according to the invention may comprises a V_(H) region which comprises one or more CDRs selected from CDR 1, CDR 2, or CDR 3, shown in FIG. 2, or one or more amino acid sequences having substantial homology to those CDRs. Additionally or alternatively, an antibody according to the invention may comprise a V_(L) region which comprises one or more CDRs selected from CDR 1, CDR 2, or CDR 3 shown in FIG. 3, or one or more amino acid sequences having substantial homology to those CDRs.

An antibody according to the invention may have a binding affinity for human full length TSHR of about 10¹⁰ L/mol. Preferably an antibody according to the invention has a binding affinity for human full length TSHR of about 10⁹ L/mol.

The invention helps the skilled addressee to understand the immunological mechanisms which drive development and production of stimulating and blocking TSHR autoantibodies. Additionally, the invention helps the skilled addressee to understand molecular differences between TSHR autoantibodies with thyroid stimulating activity and with blocking activity. In addition, the method of medical treatment and pharmaceutical compositions of the invention provide new treatments for thyroid-related conditions.

A preferred antibody in accordance with the invention is 5C9. 5C9, has been found unexpectedly to inhibit thyroid stimulating hormone receptor constitutive activity, that is to say the production of cyclic AMP in a test system in the absence of thyroid stimulating hormone or M22. This may be particularly advantageous in the treatment of thyroid cancer cells remaining in the thyroid, or in metastases, especially in preventing or delaying regrowth as those cells will grow more rapidly as a consequence of thyroid stimulating hormone receptor constitutive activity.

The term “antibody” and cognate terms, such as “antibodies”, used herein embraces according to context immunoglobulin-based binding moieties such as monoclonal and polyclonal antibodies, single chain antibodies, multi-specific antibodies and also binding moieties, which may be substituted by the skilled addressee for such immunoglobulin-based binding moieties, such as domain antibodies, diabodies, IgGΔC_(H)2, F(ab′)₂, Fab, scFv, V_(L), V_(H), dsFv, Minibody, Triabody, Tetrabody, (scFv)₂, scFv-Fc, F(ab′)₃ (Holliger P, Prospero T, Winter G 1993 “Diabodies: small bivalent and bispecific antibody fragments” Proc Natl Acad Sci USA 90: 6444-6448.), (Carter P J 2006 “Potent antibody therapeutics by design” Nat Rev Immunol 6: 343-357).

The term “TSHR” refers to full length human thyroid stimulating hormone receptors having the amino acid sequence shown in FIG. 4 or variants or fragments thereof having high homology with thyroid stimulating hormone receptors. Preferably, such variants and fragments having 70 to 99.9% homology with amino acid sequence shown in FIG. 4.

According to another aspect of the invention there is provided a nucleotide comprising:

-   -   a) a nucleotide sequence encoding an antibody according to the         first aspect of the invention;     -   b) a nucleotide sequence as shown in FIG. 2 or 3 encoding an         amino acid sequence of an antibody V_(H) domain, an antibody         V_(L) domain, or a CDR as shown in FIG. 2 or 3; or     -   c) a nucleotide sequence having high homology to nucleotide         sequences of a) or b) and encoding an antibody which binds to         TSHR with an affinity of at least about 10⁹ L/mol.

According to another aspect of the invention there is provided a vector comprising a nucleotide according to the above aspect of the invention.

The vector may be a plasmid, virus or fragment thereof. Many different types of vectors are known to the skilled addressee.

According to another aspect of the invention there is provided an isolated cell including an antibody; nucleotides or/vector according to the invention. The isolated cell may express an antibody according to the invention. Preferably, the isolated cell secretes an antibody according to the invention. Preferably an isolated cell according to the invention is from a stable hetero-hybridoma cell line.

According to a further aspect of the invention there is provided a composition comprising a defined concentration of TSHR autoantibodies and including an antibody according to the invention. Such a composition may comprise a defined concentration of TSHR autoantibodies with TSH antagonist activity, and includes an antibody according to the invention.

Alternatively, a composition according to this aspect of the invention may comprise a defined concentration of TSHR autoantibodies which are antagonists of thyroid stimulating antibodies, and includes an antibody according to the invention. A composition may comprise a defined concentration of TSHR autoantibodies with TSH antagonist activity and which are antagonists of thyroid stimulating antibodies, and includes an antibody according to the invention.

According to another aspect of the invention there is provided a pharmaceutical composition for administration to a mammalian subject for the treatment of a thyroid-related condition comprising an antibody according to the invention, together with a pharmaceutically acceptable carrier. The thyroid-related condition may be selected from thyroid overactivity, Graves' eye disease, neonatal hyperthyroidism, human chorionic gonadotrophin-induced hyperthyroidism, pre-tibial myxoedema, thyroid cancer and thyroiditis.

A pharmaceutical composition according to the invention may be suitable for human administration. Preferably a pharmaceutical composition according to the invention has no significant adverse effect on the immune system of the subject.

A pharmaceutical composition according to the invention may include an additional thyroid stimulating hormone receptor antagonist. A suitable additional thyroid stimulating hormone receptor antagonist is 9D33 as disclosed in WO2004/050708.

Various formats are contemplated for pharmaceutical compositions according to the invention. A pharmaceutical composition according to the invention for use in the treatment of a thyroid-related condition may be in an injectable format. A pharmaceutical composition according to the invention for use in the treatment of pre-tibial myxoedema is preferably in a topical format. A pharmaceutical composition according to the invention for use in the treatment of Graves' eye disease is preferably in the form of eye drops.

Pharmaceutical compositions of this invention comprise any antibody in accordance with the invention of the present invention, with any pharmaceutically acceptable carrier, adjuvant or vehicle. Pharmaceutically acceptable carriers, adjuvants and vehicles that may be used in the pharmaceutical compositions of this invention include, but are not limited to, ion exchangers, alumina, aluminium stearate, lecithin, serum proteins, such as human serum albumin, buffer substances such as phosphates, glycine, sorbic acid, potassium sorbate, partial glyceride mixtures of saturated vegetable fatty acids, water, salts or electrolytes, such as protamine sulfate, disodium hydrogen phosphate, potassium hydrogen phosphate, sodium chloride, zinc salts, colloidal silica, magnesium trisilicate, polyvinyl pyrrolidone, cellulose-based substances, polyethylene glycol, sodium carboxymethylcellulose, polyacrylates, waxes, polyethylene-polyoxypropylene-block polymers, polyethylene glycol and wool fat.

The pharmaceutical compositions of the invention may be administered orally, parenterally, by inhalation spray, topically, by eyedrops, rectally, nasally, buccally, vaginally or via an implanted reservoir. We prefer oral administration or administration by injection. The term “parenteral” as used herein includes subcutaneous, intracutaneous, intravenous, intramuscular, intra-articular, intrasynovial, intrasternal, intrathecal, intralesional and intracranial injection or infusion techniques.

The pharmaceutical compositions may be in the form of a sterile injectable preparation, for example, as a sterile injectable aqueous or oleaginous suspension. This suspension may be formulated according to techniques known in the art using suitable dispersing or wetting agents (such as, for example, Tween 80) and suspending agents. The sterile injectable preparation may also be a sterile injectable solution or suspension in a non-toxic parenterally-acceptable diluent or solvent, for example, as a solution in 1,3-butanediol. Among the acceptable vehicles and solvents that may be employed are mannitol, water, Ringer's solution and isotonic sodium chloride solution. In addition, sterile, fixed oils are conventionally employed as a solvent or suspending medium. For this purpose, any bland fixed oil may be employed including synthetic mono- or diglycerides. Fatty acids, such as oleic acid and its glyceride derivatives are useful in the preparation of injectables, as are natural pharmaceutically-acceptable oils, such as olive oil or castor oil, especially in their polyoxyethylated versions. These oil solutions or suspensions may also contain a long-chain alcohol diluent or dispersant such as Ph. Helv or a similar alcohol.

The pharmaceutical compositions of this invention may be orally administered in any orally acceptable dosage form including, but not limited to, capsules, tablets, and aqueous suspensions and solutions. In the case of tablets for oral use, carriers which are commonly used include lactose and corn starch. Lubricating agents, such as magnesium stearate, are also typically added. For oral administration in a capsule form, useful diluents include lactose and dried corn starch. When aqueous suspensions are administered orally, the active ingredient is combined with emulsifying and suspending agents. If desired, certain sweetening and/or flavouring and/or colouring agents may be added.

The pharmaceutical compositions of this invention may also be administered in the form of suppositories for rectal administration. These compositions can be prepared by mixing a compound of this invention with a suitable non-irritating excipient which is solid at room temperature but liquid at the rectal temperature and therefore will melt in the rectum to release the active components. Such materials include, but are not limited to, cocoa butter, beeswax and polyethylene glycols.

Topical administration of the pharmaceutical compositions of this invention is especially useful when the desired treatment involves areas or organs readily accessible by topical application. For application topically to the skin, the pharmaceutical composition should be formulated with a suitable ointment containing the active components suspended or dissolved in a carrier. Carriers for topical administration of the compounds of this invention include, but are not limited to, mineral oil, liquid petroleum, white petroleum, propylene glycol, polyoxyethylene polyoxypropylene compound, emulsifying wax and water. Alternatively, the pharmaceutical composition can be formulated with a suitable lotion or cream containing the active compound suspended or dissolved in a carrier. Suitable carriers include, but are not limited to, mineral oil, sorbitan monostearate, polysorbate 60, cetyl esters wax, cetearyl alcohol, 2-octyldodecanol, benzyl alcohol and water. The pharmaceutical compositions of this invention may also be topically applied to the lower intestinal tract by rectal suppository formulation or in a suitable enema formulation. Topically-transdermal patches are also included in this invention.

The pharmaceutical compositions of this invention may be administered by nasal aerosol or inhalation. Such compositions are prepared according to techniques well-known in the art of pharmaceutical formulation and may be prepared as solutions in saline, employing benzyl alcohol or other suitable preservatives, absorption promoters to enhance bioavailability, fluorocarbons, and/or other solubilising or dispersing agents known in the art.

According to a further aspect of the invention there is provided a method of producing an antibody according to the invention, the method comprising culturing one or more isolated cells according to the invention whereby the antibody is expressed by the cell. Preferably, the antibody is secreted by the cell.

According to a further aspect of the invention there is provided a method of treating a thyroid-related condition in a mammalian subject, or in cells derived from the subject, the method comprising contacting the subject, or the cells, with an antibody according to the invention.

According to another aspect of the invention there is provided a method of inhibiting thyroid stimulating autoantibodies stimulating the TSHR in the thyroid of a mammalian subject, the method comprising contacting the subject with an antibody according to the invention. Preferably binding of thyroid stimulating autoantibodies to the TSHR is prevented.

According to another aspect of the invention there is provided a method of inhibiting thyroid stimulating autoantibodies binding to extra-thyroidal TSHRs in a mammalian subject, the method comprising contacting the subject with an antibody according to the invention. The extra-thyroidal TSHRs may be in retro-orbital tissues and/or pre-tibial tissue of the subject. The antibody of the invention preferably blocks TSHR autoantibodies binding to extra-thyroidal TSHRs when used in the method.

According to another aspect of the invention there is provided a method of treating thyroid cancer in the thyroid, or in metastases, in a subject or in thyroid cells derived from a subject, the method comprising contacting the cancerous cells with an antibody according to the invention, in order to inhibit constitutive thyroid stimulating hormone receptor activity in the cells. Preferably regrowth of thyroid cancer cells is prevented or delayed.

There is also provided a method of treating thyroid overactivity due to constitutive thyroid activity, in a subject or in thyroid cells derived from a subject, the method comprising contacting the subject or thyroid cells with an antibody according to the invention, in order to inhibit thyroid overactivity due to constitutive thyroid activity.

The subject treated in the various methods of the invention described above is preferably human.

According to another aspect of the invention there is provided the use of an antibody according to the invention in the treatment of a thyroid-related condition. Alternatively there is provided the use of an antibody according to the invention in the preparation of a medicament for the treatment of a thyroid-related condition.

There is also provided an antibody according to the invention for use in medical therapy. In particular, there is provided the use of an antibody according to the invention for use in the treatment of a thyroid-related condition. The thyroid-related condition may be selected from thyroid overactivity, Graves' eye disease, neonatal hyperthyroidism, human chorionic gonadotrophin-induced hyperthyroidism, pre-tibial myxoedema, thyroid cancer and thyroiditis.

According to another aspect of the invention there is provided a method of characterising TSHR antibodies comprising determining binding of a TSHR antibody under test to a polypeptide having a TSHR-related amino acid sequence in which the method involves a method step including the use of an antibody according to the invention. Preferably the method comprises determining the effects of an antibody according to the invention on binding of a TSHR antibody to that polypeptide. The polypeptide having a TSHR-related amino acid sequence preferably comprises full length human TSHR.

According to another aspect of the invention there is provided a method for characterising TSH and related molecules, comprising determining binding of TSH, or a related molecule under test, to a polypeptide having a TSHR-related amino acid sequence, in which the method involves a method step including the use of an antibody according to the invention.

Methods for characterising TSHR antibodies, or TSH and related methods described above may be in an ELISA format.

According to another aspect of the invention there is provided a method of determining TSHR amino acids involved in binding TSHR autoantibodies which act as antagonists, the method comprising providing a polypeptide having a first TSHR-related amino acid sequence to which an antibody according to the invention binds, modifying at least one amino acid in the TSHR-related amino acid sequence and determining the effect of such modification on binding of the antibody.

A method of modifying an antibody according to the invention, the method comprising modifying at least one amino acid of the antibody and determining an effect of such a modification on binding to a TSHR-related sequence. Preferably modified TSHR antibodies are selected which have an enhanced affinity for the TSHR.

According to another aspect of the invention there is provided a method of identifying molecules which inhibit thyroid stimulating antibodies binding to the TSHR, the method comprising providing at least one antibody according to the invention as reference. Preferably molecules under test which prevent thyroid stimulating antibodies binding to the TSHR are selected.

There is also provided a method of identifying molecules which inhibit thyroid blocking antibodies binding to the TSHR, the method comprising providing at least one antibody according to the invention as reference. Preferably molecules which prevent thyroid blocking antibodies binding to TSHR are selected.

BRIEF DESCRIPTION OF THE DRAWINGS

Antibodies and methods in accordance with the invention will now be described, by way of example only, with reference to the accompanying drawings, FIGS. 1 to 4, in which FIG. 1 is a series of three graphs illustrating a comparison of the effects of sera from patients with Graves' disease (n=40) and healthy blood donors (n=10) on ¹²⁵I-5C9 IgG, ¹²⁵I-TSH or ¹²⁵I-M22 binding to TSHR coated tubes.

-   -   a ¹²⁵I-5C9 IgG vs ¹²⁵I-TSH binding     -   b ¹²⁵I-5C9 IgG vs ¹²⁵I-M22 IgG binding     -   c ¹²⁵I-TSH vs ¹²⁵I-M22 IgG binding;

FIG. 2 gives sequences of the variable region sequences of 5C9 heavy chain (HC)

-   -   a the oligonucleotide sequence of 5C9 HC shown in unannotated         and annotated forms. In the annotated forms, sequences used for         PCR primers are individual Complementarity Determining Regions         (CDRs) are boxed; and constant regions are bold.     -   b the amino acid sequence of 5C9 HC derived from the         oligonucleotide sequence shown in unannotated and annotated         forms;

FIG. 3 gives sequences of the variable region sequences of 5C9 light chain (LC):

-   -   a the oligonucleotide sequence of 5C9 LC shown in unannotated         and annotated (as per FIG. 2) forms     -   b the amino acid sequence of 5C9 LC derived from the         oligonucleotide sequence shown in unannotated and annotated         forms; and

FIG. 4 illustrates the consensus amino acid sequence of the human TSHR (accession no. P16473).

DETAILED DISCLOSURE

Methods

Lymphocyte Isolation and Cloning of the Human Monoclonal TSHR Autoantibody 5C9

The monoclonal autoantibody 5C9 was isolated generally using the procedure described in WO2004/050708A2. Lymphocytes were first isolated from a blood sample collected from a patient with postpartum hypothyroidism and high levels of TRAbs (Local Ethical Committee approval was obtained). The lymphocytes were infected with Epstein Barr Virus (EBV) (European Collection of Cell Cultures—ECACC; Porton Down, SP4 0JG,UK) and cultured on mouse macrophage feeder layers as described in WO2004/050708A2. Immortalised lymphocytes secreting TSHR autoantibodies were fused with a mouse/human hybrid cell line K6H6/B5 (ECACC) and cloned four times by limiting dilution to obtain a single colony. The presence of TSHR autoantibody in cell culture supernatants at different stages of cloning was detected by inhibition of ¹²⁵I-labelled TSH binding to the TSHR (WO2004/050708A2). A single clone producing the TSHR autoantibody was expanded and supernatants from the cultures were harvested for autoantibody purification.

Purification and Labelling of 5C9 IgG Preparations

5C9 IgG was purified from culture supernatants using protein A affinity chromatography on MabSelect™ (GE Healthcare, UK) as described in Sanders J, Jeffreys J, Depraetere H, Evans M, Richards T, Kiddie A, Brereton K, Premawardhana L D, Chirgadze D Y, Nunez Miguel R, Blundell T L, Furmaniak J, Rees Smith B 2004 Characteristics of a human monoclonal autoantibody to the thyrotropin receptor: sequence structure and function. Thyroid 2004 14: 560-570) and purity assessed by SDS-polyacrylamide gel electrophoresis (PAGE).

The heavy chain isotype of 5C9 was determined using a radial diffusion assay (The Binding Site; Birmingham, B29 6AT, UK), and the light chain isotype was determined by Western blotting with anti-human kappa chain and anti-human lambda chain specific mouse monoclonal antibodies (Sigma-Aldrich Company Ltd, Poole, UK).

5C9 IgG at 10 mg/mL in 20 mmol/L sodium acetate pH 4.5 was incubated with immobilized pepsin prepared according to the manufacturer's instructions (Perbio Science UK Ltd, Cramlington, UK) for 4½ hours at room temperature with shaking. Thereafter, immobilised pepsin was removed by centrifugation (1000×g, 5 minutes at room temperature) and the supernatant dialysed against 300 mmol/L NaCl, 10 mmol/L Tris-HCl pH 7.5 overnight at 4° C. The dialysed mixture containing 5C9 F(ab′)2 and small amounts of intact IgG was separated using a Sephacryl S-300 High Resolution Matrix (GE Healthcare, Chalfont St Giles, UK). The 5C9 F(ab′)₂ preparations purified in this way did not contain intact IgG as judged by SDS-PAGE and HPLC gel filtration analyses.

Furthermore, F(ab′)₂ was reduced using a final concentration of 100 mmol/L L-cysteine for 1 hour at 37° C. The reaction was stopped with a final concentration of 50 mmol/L iodoacetamide for 30 minutes at room temperature. The F(ab′) was purified using a Sephacryl S-300 column as above. F(ab′) preparations purified in this way did not contain F(ab′)₂ as judged by SDS-PAGE and HPLC gel filtration analysis.

In addition, 5C9 IgG was treated with mercuripapain (Sigma, UK) at an enzyme/protein ratio of 1:100 dialysed into 50 mmol/L NaCl, Tris-HCl pH 9.0 and passed through an anion exchange Sepharose (Q-Sepharose Fast flow from GE Healthcare) column to separate intact IgG or Fc from the Fab preparation. Analysis by SDS-PAGE and gel filtration (Sephacryl S-300 column; as above) indicated that intact IgG was undetectable in the Fab preparation.

5C9 IgG was labelled with ¹²⁵I as described in Sanders J, Oda Y, Roberts S, Kiddie A, Richards T, Bolton J, McGrath V, Walters S, Jaskolski D, Furmaniak J, Rees Smith B 1999. The interaction of TSH receptor autoantibodies with ¹²⁵I-labelled TSH receptor. Journal of Clinical Endocrinology and Metabolism. 1999 84: 3797-3802) or with biotin hydrazide (Perbio Science, Cramlington, UK).

Inhibition of ¹²⁵I-TSH or ¹²⁵I-M22 or ¹²⁵I-5C9 Binding to the TSHR

Binding inhibition assays were carried out using TSHR coated tubes as described in WO2004/050708A2. In the assay, 100 μL of test sample (MAb preparation, patient serum or unlabelled TSH) and 50 μL of start buffer (RSR Ltd) were incubated in TSHR coated tubes for 2 hours at room temperature with gentle shaking. After aspiration, the tubes were washed and 100 μL of ¹²⁵I-labelled protein (5×10⁴ cpm) added and incubated for 1 hour at room temperature with shaking. The tubes were then aspirated, washed and counted in a gamma counter.

Inhibition of labelled protein binding was calculated as:—

$100 \times \left\lbrack {1 - \frac{{cpm}\mspace{14mu}{bound}\mspace{14mu}{in}{\mspace{11mu}\;}{the}\mspace{14mu}{presence}\mspace{14mu}{of}\mspace{14mu}{test}\mspace{14mu}{material}}{{cpm}\mspace{14mu}{bound}\mspace{14mu}{in}\mspace{14mu}{the}\mspace{14mu}{presence}\mspace{14mu}{of}\mspace{14mu}{control}\mspace{14mu}{material}}} \right\rbrack$ Control material was a pool of healthy blood donor sera or individual healthy blood donor sera or other materials as indicated in the results of various experiments. Scatchard Analysis of 5C9 IgG Binding to the TSHR

Unlabelled 5C9 IgG in 50 μL of assay buffer (50 mmol/L NaCl, 10 mmol/L Tris pH 7.8 and 1% Triton X-100) and 50 μL of ¹²⁵I-labelled 5C9 IgG (30,000 cpm in assay buffer) were incubated in TSHR coated tubes for 2 hours at room temperature with shaking (maximum binding occurred under these conditions), aspirated, washed twice with 1 mL of assay buffer and counted in a gamma counter. The concentration of IgG bound vs bound/free was plotted (Scatchard G 1949 The attraction of proteins for small molecules and ions. Annals of the New York Academy of Sciences 51: 660-672) to derive the association constant.

Analysis of Stimulation of Cyclic AMP Production

The ability of 5C9 IgG and other preparations to stimulate production of cyclic AMP in Chinese hamster ovary (CHO) cells transfected with the human TSHR was tested as described in WO2004/050708A2. CHO cells expressing either approximately 5×10⁴ or approximately 5×10⁵ TSHR per cell were seeded into 96-well plates at 3×10⁴ cells per well, adapted into DMEM (Invitrogen Ltd, Paisley, UK) without foetal calf serum and then test samples (TSH, IgG or patient serum) added (100 μL diluted in cyclic AMP assay buffer i.e. NaCl free Hank's Buffered Salts solution containing 1 g/L glucose, 20 mmol/L HEPES, 222 mmol/L sucrose, 15 g/L bovine serum albumin and 0.5 mmol/L 3 isobutyl-1-methylxanthine pH 7.4) and incubated for 1 hour at 37° C. After removal of test solutions, cells were lysed and cyclic AMP concentration in the lysates assayed by one of two methods: 1) using a Biotrak enzyme immunoassay system from GE Healthcare, Chalfont St Giles, UK; or 2) using Direct Cyclic AMP Correlate—EIA kits from Assay Designs; Cambridge Bioscience, UK. Results are expressed as pmol/mL of cyclic AMP in the cell lysate (200 μl) or as fmol per cell well.

Measurement of Antagonist (Blocking) Activity

The ability of 5C9 IgG and other preparations to inhibit the stimulating activity of porcine (p) TSH, native human (h) TSH and recombinant human (rh) TSH, MAb M22 and patient serum TRAbs in CHO cells expressing TSHRs was assessed. This was carried out by comparing the stimulatory effect of TSH, M22 or TRAbs in the absence and in the presence of 5C9 IgG (or other preparations being tested). The assay was carried out as described above except 50 μL of 5C9 (or other preparations being tested) diluted in cyclic AMP assay buffer was added to the cell wells followed by 50 μL of TSH or M22 or patient serum (diluted as appropriate in cyclic AMP assay buffer) and incubated and tested as for the stimulating assay described above.

Other MAbs and sera from patients with blocking type TRAbs were tested in this assay in addition to 5C9.

Variable Region Gene Analysis

The variable region genes of the 5C9 heavy and light chains were determined as described in WO2004/050708A2, using total RNA prepared from 1×10⁷ hetero-hybridoma cells secreting 5C9 IgG to produce mRNA for RT-PCR (reverse transcriptase PCR) reactions. Specific IgG1 HC and kappa LC sense and antisense strand oligonucleotide primers were designed using the Medical Research Council's V-base and synthesised by Invitrogen (Paisley, PA4 9RF, UK). The RT reaction was carried out at 50° C. for 15 minutes followed by 40 cycles of PCR at 94° C. for 15 seconds, 50° C. for 30 seconds and 72° C. for 30 seconds. DNA products were cloned into pUC18 and sequenced by the Sanger-Coulson method (Sanger F, Nicklen S, Coulson AR 1977 DNA sequencing with chain terminating inhibitors. Proceedings of the National Academy of Sciences of USA 74: 5463-5467). V region sequences were compared with available sequences of human Ig genes using Ig blast.

Analysis of the Effects of Amino Acid Mutations in the Human TSHR Sequence on 5C9 Activity.

The methods used to introduce specific mutations into the TSHR sequence have been described in patent application WO2006/016121A. Furthermore, the transfection of mutated TSHR constructs into CHO cells using the Flp-In system is also described in WO2006/016121A.

Flp-In-CHO cells expressing either wild type or mutated TSHRs were seeded into 96 well plates and used to test the ability of 5C9 preparations to block the stimulating activity of TSH, M22 or patient serum TRAbs as described above.

5C9 Based Assays for TSHR Antibodies, TSH and Related Molecules.

5C9 IgG at 2.55 mg/mL was dialysed into 100 mmol/L sodium phosphate buffer pH 8.5 and reacted with EZ-Link NHS-LC-Biotin (Perbio) using a molar ratio of IgG to biotin of 1/10. Test serum samples (75 μL) were incubated in TSHR-coated ELISA plate wells (RSR Ltd) for 2 hours at room temperature with shaking (500 shakes per minute). After removing the test samples and washing, biotin labelled 5C9 IgG (2 ng in 100 μL) was added and incubation continued for 25 min at room temp without shaking. The wells were emptied, washed and 100 μL streptavidin-peroxidase (10 ng in 100 μL; RSR Ltd) was added and incubated for 20 min at room temperature without shaking. The wells were then washed three times, the peroxidase substrate tetramethyl benzidine (TMB; 100 μL; RSR Ltd) was added and incubated for 30 minutes at room temperature in the dark without shaking. 50 μL of 0.5 mol/L H2SO4 was then added to stop the reaction and the absorbance of each plate well was read at 450 nm using an ELISA plate reader. Inhibition of 5C9 IgG-biotin binding was calculated as:—

$100 \times \left\lbrack {1 - \frac{{test}\mspace{14mu}{sample}\mspace{14mu}{absorbance}\mspace{14mu}{at}\mspace{14mu} 450\mspace{14mu}{nm}}{{negative}\mspace{14mu}{control}\mspace{14mu}{serum}\mspace{14mu}{absorbance}\mspace{14mu}{at}\mspace{14mu} 450\mspace{14mu}{nm}}} \right\rbrack$ Results Isolation and Cloning of the 5C9 Secreting Cell Line

Lymphocytes (27×10⁶) obtained from 20 mL of patient's blood were infected with EBV and plated out at 1×10⁶ cells per well in a 48 well plate on feeder layers of mouse macrophages. On day 13 post EBV infection the plate well supernatants were monitored for inhibition of ¹²⁵I-TSH binding. Cells from the positive wells were expanded and fused with the K6H6/B5 hybridoma cell line and plated out in 96 well plates. One clone stably producing antibody with ¹²⁵I-TSH binding inhibiting activity was obtained and re-cloned 4 times. The monoclonal antibody, designated as 5C9, purified from hetero-hybridoma culture supernatants was subclass IgG1 with kappa light chains.

TSHR Binding and Blocking Activities of 5C9 IgG

The ability of different concentrations of 5C9 IgG to inhibit binding of labelled TSH or labelled M22 or labelled 5C9 itself to the TSHR is shown in Table 1. As shown in Table 1, 12% inhibition of ¹²⁵I-TSH binding was observed with as little as 0.005 μg/mL of 5C9 IgG and the inhibition increased in a dose dependent manner up to 84% inhibition at 100 μg/mL of 5C9. This can be compared to ¹²⁵I-TSH binding inhibition by donor serum IgG; 13% inhibition at 0.05 mg/mL increasing in a dose dependent manner to 94% inhibition at 1 mg/mL. In the case of donor plasma, 16% inhibition of ¹²⁵I-TSH binding was observed at 1:160 dilution in healthy blood donor pool serum and 95% inhibition at 1:10 dilution.

5C9 IgG also had an effect on binding of ¹²⁵I-M22 IgG to the TSHR coated onto the tubes (Table 1). 9% inhibition of ¹²⁵I-M22 IgG binding was observed at 0.01 μg/mL of 5C9 IgG and increasing concentrations resulted in a dose dependent increase of inhibition up to 85% at 100 μg/mL. Donor serum IgG was effective at 0.01 mg/mL causing 9% inhibition and the effect increased in a dose dependent manner to 89% inhibition at 1 mg/mL. Donor serum plasma showed 13% inhibition of ¹²⁵I-M22 IgG binding at 1:320 dilution and 91% inhibition at 1:10 dilution.

Unlabelled 5C9 IgG was able to inhibit ¹²⁵I-5C9 binding to the TSHR coated tubes in a dose dependent manner (11% inhibition at 0.005 μg/mL up to 88% inhibition at 100 μg/mL) (Table 1). Binding of ¹²⁵I-5C9 was also inhibited by donor serum IgG (15% inhibition at 0.05 mg/mL and 91% inhibition at 1 mg/mL) as well as dilutions of donor plasma (10% inhibition at 1:320 dilution and 92% at 1:10 dilution).

The ability of 5C9 IgG to block TSH and M22-mediated stimulation of cyclic AMP in CHO cells expressing the TSHR is shown in Tables 2a-c. Porcine TSH (3 ng/mL) strongly stimulated cyclic AMP production (19,020±2154 fmol/cell well; mean±SD; n=3) (Table 2a). In the presence of 0.1 μg/mL of 5C9 IgG the stimulating activity of porcine TSH was reduced to 11874±4214 fmol/cell well (mean±SD; n=3) and the inhibiting effect was dependent on 5C9 concentration with only 2,208±329 fmol/cell well of cyclic AMP produced in the presence of 1 μg/mL of 5C9 (Table 2a). The lymphocyte donor serum also had a strong inhibiting effect on TSH mediated cyclic AMP stimulation in CHO-TSHR cells. As shown in Table 2a, inhibition of cyclic AMP production down to approximately 6000 Enol/cell well occurred in the presence of donor serum at 1:10 dilution (total serum IgG concentration at this dilution of 1.43 mg/mL) compared to 19000 fmol/cell well in the absence of serum. This effect corresponded to the effect of approximately 0.37 μg/mL of purified 5C9 IgG (calculated from the dilution curve of the effect of different concentrations of 5C9 IgG shown in Table 2a). This indicates that purified 5C9 IgG is approximately 3900 times more active than the donor serum IgG in terms of ability to block the ability of TSH to stimulate cyclic AMP production.

Fragments of 5C9, such as 5C9 F(ab′)₂ and 5C9 Fab were also effective inhibitors of TSH stimulation. In particular, TSH stimulation inhibiting activity of 5C9 IgG, 5C9 F(ab′)₂ and 5C9 Fab at 100 μg/mL were the same (Table 2b). At 10 μg/mL all three preparations: 5C9 IgG, 5C9 F(ab′)₂ and 5C9 Fab were also potent inhibitors of TSH stimulating activity, however, 5C9 IgG appeared to be more effective than 5C9 F(ab′)₂ or 5C9 Fab (Table 2b).

M22 Fab (3 ng/mL) is a potent stimulator of cyclic AMP (9,432±822 fmol/cell well) (Table 2c) and in the presence of 5C9 the stimulating effect of M22 Fab was inhibited in a dose dependent manner, with cyclic AMP levels reduced to 1,298±134 fmol/cell well in the presence of 0.1 μg/mL of 5C9 IgG. Complete inhibition of M22 stimulation occurred at 100 μg/mL of 5C9 (Table 2c).

Scatchard analysis indicated that ¹²⁵I-labelled 5C9 bound to the TSHR with an association constant of 4×10¹⁰ L/mol.

Inhibition of ¹²⁵I-5C9 IgG Binding to the TSHR by Serum TRAbs

The ability of serum TRAbs to inhibit ¹²⁵I-5C9 IgG binding to TSHR coated tubes is shown in Table 3 and FIG. 1. The effect of the same serum TRAbs on binding of ¹²⁵I-TSH and binding of ¹²⁵I-M22 IgG is also shown for comparison.

Binding of ¹²⁵I-5C9 IgG to the TSHR was not markedly inhibited (inhibition range 3.4-18.9%) by sera from 10 different healthy blood donors (N1-N10, Table 3). Sera from 40 patients with Graves' disease (G1-G40, Table 3) all positive for TSHR autoantibodies in ¹²⁵I-TSH and ¹²⁵I-M22 inhibition assays (Table 3) inhibited ¹²⁵I-5C9 binding to TSHR coated tubes (inhibition range 22.0-85.2%) to a greater extent than sera from healthy blood donors (Table 3). The ability of patient serum TRAbs to inhibit ¹²⁵I-5C9 IgG, ¹²⁵I-TSH or ¹²⁵I-M22 IgG binding to the TSHR was comparable with a Pearson correlation coefficient r=0.95 (¹²⁵I-5C9 IgG versus ¹²⁵I-TSH; FIG. 1 a) and r=0.95 (¹²⁵I-5C9 IgG versus ¹²⁵I-M22 IgG; FIG. 1 b). FIG. 1 c shows comparison of inhibition of ¹²⁵I-TSH and ¹²⁵I-M22 IgG by the same sera (Pearson coefficient r=0.99).

These experiments show that 5C9 IgG binding to the TSHR is inhibited effectively by serum TRAbs and that the inhibiting effect of serum TRAb on 5C9 IgG binding is similar to their inhibiting effect on TSH or M22 binding.

Table 4 shows the inhibition of ¹²⁵I-5C9 IgG binding by different dilutions of patient serum TRAbs with TSH blocking activity (B1-B5) and patient serum TRAbs with powerful thyroid stimulating activity (S1, S2, S4). Binding of ¹²⁵I-5C9 IgG was inhibited in a dose dependent manner by sera B1-B5 sera as well as by sera S1, S2 and S4. The same blocking and stimulating sera also inhibited ¹²⁵I-TSH and ¹²⁵I-M22 IgG binding in a dose dependent manner, furthermore the percentage of inhibition with all three labelled ligands were comparable at the same dilutions of sera (Table 4a & b).

These results indicate that TSHR autoantibodies with both stimulating and blocking activities inhibit 5C9 binding to the TSHR.

Inhibition of ¹²⁵I-5C9 IgG Binding to the TSHR by Mouse MAbs with TSH Binding Inhibiting Activity

The ability of different mouse TSHR MAbs with ¹²⁵I-TSH binding inhibiting activity to inhibit ¹²⁵I-5C9 binding to the TSHR was tested and compared with the effect on ¹²⁵I-M22 IgG binding (Table 5). As shown in Table 5 all MAbs that had ability to inhibit ¹²⁵I-TSH and ¹²⁵I-M22 IgG binding also inhibited ¹²⁵I-5C9 binding although in the case of some MAbs the inhibiting effect on ¹²⁵I-5C9 and ¹²⁵I-M22 binding was weaker than that on ¹²⁵I-TSH binding.

These experiments suggest that there is a considerable overlap between the binding sites on the TSHR for 5C9 and those for mouse TSHR MAbs which have the ability to inhibit TSH binding.

Effect of 5C9 IgG on Stimulation of Cyclic AMP Production in CHO Cells Expressing TSHRs by Patient Sera

As shown in Table 2, 5C9 IgG was able to block TSH or M22 stimulation of cyclic AMP levels in CHO cells expressing TSHRs. In a different series of experiments the effect of 5C9 IgG on the stimulating activity of patient serum TRAbs was tested and the results are shown in Table 6a. Sera T1-T9 and T11-T18 stimulated cyclic AMP production in CHO-TSHR cells and incubation with a control MAb IgG (2G4 specific for human thyroid peroxidase) had no effect on their stimulating activities. However, in the presence of 5C9 IgG (50 μL of 200 μg/mL), the stimulating activity of all sera tested was markedly reduced (Table 6a).

Dose response effects of 6 different sera (T1, T6, T3, T19, T20, T21) are shown in Tables 6b-g. In these experiments, concentrations of 5C9 IgG ranging from 0.1 μg/mL to 100 μg/mL caused a dose dependent reduction of serum stimulating activity and the effect of 5C9 IgG was comparable to the effect of 9D33, a mouse monoclonal antibody to the TSHR with blocking activity (described in WO2004/050708A2) in all sera tested except serum T3. In the case of T3 serum (Table 6a & 6d) about 50% inhibition of cyclic AMP production in the presence of 100 μg/mL of 5C9 IgG was observed, whereas 100 μg/mL of 9D33 IgG resulted in almost complete inhibition. This suggested that there might be some minor differences between the epitopes recognised by 5C9 and 9D33.

Effect of 5C9 IgG on Basal (i.e. Non-Stimulated) Cyclic AMP Production in CHO Cells Expressing TSHR

As well as inhibiting the stimulating activity of TSH and TSHR antibodies, 5C9 inhibited the amount of cyclic AMP produced in the absence of these thyroid stimulators. In particular, Table 6b shows 1207±123 fmol/cell well of cyclic AMP produced in the presence of 100 μg/mL control monoclonal IgG (2G4) reduced to 301±38 fmol/cell well in the presence of 100 μg/mL of 5C9 IgG. The effects of 9D33 IgG were less with 721±183 fmol/cell well produced in the presence of 100 μg/mL 9D33 IgG. Similar results were obtained in the separate experiments shown in Tables 6d, 6e, 6f and 6g. This indicates that 5C9 IgG has a marked effect on the basal or constitutive activity of the TSHR.

Effect of 5C9 IgG on Stimulation of Cyclic AMP Production in CHO Cells Expressing TSHRs Containing Amino Acid Mutations

The effects of single amino acid mutations in the TSHR on 5C9 ability to block cyclic AMP stimulating activity of porcine TSH in CHO-TSHR cells are shown in Table 7. In particular, the effect of 5C9 on stimulation of cyclic AMP production was studied in CHO cells expressing the TSHR with the following residues mutated to alanine: Lys 58, Ile 60, Arg 80, Tyr 82, Thr 104, Arg 109, Lys 129, Phe 134, Asp 151, Lys 183, Gln 235, Arg 255, Trp 258, Ser 281. In addition, the effect of a change of charge mutation was studied in the case of TSHR residues: Arg80Asp, Asp151Arg, Lys183Asp, Arg255Asp, in which in accordance with conventional notation the amino acid residue which is replaced, and its position in the primary sequence polypeptide, is indicated before the replacement amino acid residue. Previous studies have shown that change of charge mutation of TSHR Asp160Lys caused a loss of responsiveness of the TSHR to TSH while the response to M22 was not affected (patent application WO2006/016121A). Consequently, the effect of TSHR Asp160Lys mutation on 5C9 biological activity was studied using M22 as a stimulator of cyclic AMP in CHO-TSHR cells (Table 71).

Out of all the TSHR mutations studied, only three mutations were found to affect the ability of 5C9 to act as an antagonist. Mutation of Lys129 to Ala (Table 7h) resulted in a complete loss of the ability of 5C9 IgG to block TSH stimulation of cyclic AMP production.

Also TSHR mutation Lys183Ala caused a partial reduction of 5C9 IgG blocking activity; 28% inhibition of TSH stimulation was observed at 1 μg/mL when tested with TSHR Lys183Ala mutation compared to 84% inhibition with wild type TSHR (Table 7m). Even at 100 μg/mL of 5C9 IgG, only partial inhibition of TSH stimulation (43%) was detectable in the experiments with TSHR Lys183Ala mutation whereas at this concentration a complete blocking of TSH stimulating activity (93%) was observed in the experiments with wild type receptors (Table 7m). When positively charged Lys 183 was mutated to negatively charged aspartic acid, the effect on 5C9 biological activity was similar to that observed with Lys183 Ala mutation (Table 7m). This suggests that Lys183 is important for 5C9 biological activity. In the case of Asp151Ala mutation, a slight reduction of 5C9 IgG blocking activity: 49% inhibition at 1 μg/mL compared to 88% inhibition with wild type (Table 7j) was observed. However, in the presence of 100 μg/mL of 5C9 IgG the activity was the same as with wild type TSHR. When negatively charged Asp151 was mutated to positively charged arginine, a significant reduction in 5C9 IgG blocking activity was not observed (Table 7k).

The effect of TSHR mutations on 5C9 activity can be compared to the effects of TSHR mutations on 9D33 activity. As described in patent application WO2006/016121A, TSHR mutations Lys 58, Arg 80, Tyr 82, Arg 109, Lys 129 and Phe 134 had an effect on 9D33 activity. None of these mutations except Lys129, however, also had an effect on 5C9 activity. Furthermore, none of the mutations except Lys 129 that affected M22 activity (Arg 80, Tyr 82, Glu 107, Arg 109, Lys 129, Phe 130, Lys 183, Tyr 185, Arg 255 and Trp 258) as described in the patent application WO 2006/016121A affected 5C9 activity. In addition, Lys 183 mutation had a partial effect on 5C9 activity and M22 activity but had no effect on 9D33 activity.

These results indicate that there are differences in terms of the TSHR residues important for interaction with the thyroid stimulating human autoantibody M22, with mouse blocking antibody 9D33 and with human blocking autoantibody 5C9. Consequently, a combination of 5C9 with other TSHR antibodies with antagonist activities (such as 9D33) may be a particularly effective means of inhibiting the stimulating activity of patient serum TRAbs, other stimulators and/or TSHR constitutive activity.

Variable Region Sequences of 5C9

Sequence analysis of the genes coding for 5C9 indicated that the HC V region genes were from the VH3-53 family, the D genes from the D2-2 family and the J genes from the JH4 family. In the case of the LC, V region genes were from the 012 family and J region genes from the JK2 germline. The HC nucleotide and amino acid sequences are shown in FIGS. 2 a and 2 b, respectively and the LC nucleotide and amino acid sequences are shown in FIGS. 3 a and 3 b, respectively.

There are somatic mutations in the HC gene sequence compared to the germline sequences; in particular 1 silent mutation in FWR1, 2 replacement mutations in CDR2, 1 silent and 1 replacement mutation in CDR3 and 1 silent mutation in FWR4. However, the HC V region sequence is characterised by two insertions; one 6 base pairs long between the V and D genes and one 15 base pairs long between the D and J genes. Consequently, the HC CDR1 is 5 amino acids long, CDR2 is 16 amino acids long and the CDR3 is 18 amino acids long (FIG. 2 b)

In the LC sequence there are: 1 silent mutation in FWR1, 1 replacement mutation in CDR1, 1 replacement mutation in CDR3 and a 6 base pairs long insertion between the V and J genes. The LC CDR1 is made up of 11 amino acids, CDR2 of 7 amino acids and CDR3 of 10 amino acids (FIG. 3 b).

5C9 Based Assays for Detection of TSH or TRAbs

An example of an ELISA based on 5C9 IgG-biotin binding to TSHR coated plate wells for detection of TSHR autoantibodies is shown in Table 8. In this assay all samples positive for inhibition of TSH-biotin binding were also positive for 5C9 IgG-biotin binding. Furthermore, the absorbance signal, the percent inhibition and the derived units/L values were comparable in the TSH-biotin and 5C9-biotin assays (Table 8).

Effect of 5C9 IgG on Stimulating Activity of Mouse Thyroid Stimulating Monoclonal Antibodies (Mouse TSHR MAbs; TSMAbs) in CHO Cells Expressing TSHRs

As shown in Table 9, 5C9 IgG was able to block the stimulation of cyclic AMP production by all five of the TSMAbs (1, 2, 4, 5 and 7) tested. For example TSMAb1 (Table 9) stimulated cyclic AMP levels to 18.94±7.4 pmol/mL while in the presence of 100 μg/mL 5C9 IgG only 1.24±0.07 pmol/mL of cyclic AMP was produced. This can be compared to 16.5±1.1 pmol/mL cyclic AMP levels in the presence of 100 μg/mL of the control MAb 2G4 (Table 9).

The cyclic AMP levels shown in Tables 9, as well as in Tables 10-15 below, are expressed in pmol/mL i.e. the levels of cyclic AMP per cell well are: pmol/mL÷5 (representing 200 μL of sample from each well assayed).

Effect of 5C9 IgG on Stimulating Activity of Native Human TSH and Recombinant Human TSH In CHO Cells Expressing TSHRs

The ability of 5C9 IgG to block the cyclic AMP stimulation of porcine TSH is shown in Table 2 and Table 10. In addition 5C9 IgG showed the ability to inhibit cyclic AMP stimulation of both native human TSH (NIBSC reference preparation 81/565 from National Institute for Biological Standards and Control, South Mimms, Potters Bar EN6 3QG UK) and recombinant TSH (NIBSC reference preparation 94/674) (Table 10). In particular stimulation of cyclic AMP production by 100 ng/mL of either recombinant or native human TSH requires 0.1-1.0 μg/mL of 5C9 IgG to obtain complete inhibition of cyclic AMP production. At the time of blood collection for 5C9 isolation the levels of circulating TSH in the donor serum were 160 mU/L (approximately 32 ng/mL), the results obtained (Table 2a and Table 10) indicate that this level of circulating TSH would be completely blocked in the presence of 32-320 ng/mL of 5C9 IgG in the serum. The levels of TSHR autoantibodies in the donor serum were estimated, using inhibition of ¹²⁵I-M22 binding to the TSHR (as described in Nakatake N, Sanders J, Richards T, Burne P, Barrett C, Dal Pra C, Presotto F, Betterle C, Furmaniak J, Rees Smith B 2006 Estimation of serum TSH receptor autoantibody concentration and affinity. Thyroid 16: 1077-1084), to be 1700 ng/mL (120 ng/mg) i.e. several fold higher than the concentration of 5C9 required for blocking of thyroid stimulation by TSH.

Effect of 5C9 IgG on Basal (i.e. Non-Stimulated) Cyclic AMP Activity in CHO Cells Expressing TSHR with Activating Mutations S281I, I568T and A623I

5C9 IgG was able to reduce the amount of cyclic AMP produced in CHO cells expressing TSHR with activating mutations when thyroid stimulators (i.e. TSH or TSHR antibodies) were absent. As shown in Table 11a the basal cyclic AMP concentration in CHO cells expressing the TSHR with activating mutation S281I was 9.90±1.51 pmol/mL in the absence of 5C9 and this was decreased to 4.17±0.60 pmol/mL in the presence of 0.01 μg/mL 5C9 IgG and to 3.44±0.63 pmol/mL in the presence of 1 μg/mL 5C9 IgG. The blocking mouse TSHR MAb 9D33 had little effect as did the control MAb 2G4 (Table 11a).

Similar results were obtained with the TSHR activating mutation I568T (Table 11b), which showed a basal cyclic AMP concentration of 21.39±5.31 pmol/mL. This decreased to 5.29±0.75 pmol/mL on addition of 1 μg/mL of 5C9 IgG compared to 20.52±0.95 pmol/mL and 21.65±1.99 pmol/mL in the case of addition of 2G4 IgG and 5C9 IgG, respectively. In the case of a third TSHR activating mutation studied i.e. A623I with basal cyclic AMP concentration of 36.89 pmol/mL addition of 1 μg/mL of 5C9 IgG reduced the cyclic AMP levels to 16.43±1.27 pmol/mL compared to little effects with 1 μg/ml of control IgG 2G4 (28.96±2.29 pmol/mL) or 1 μg/mL of 9D33 IgG (40.09±7.73 pmol/mL) (Table 11c).

These results indicate that 5C9 unlike the mouse blocking MAb 9D33 has a marked effect on cyclic AMP production associated with the TSHR activating mutations even when the mutations are in different parts of the TSHR (i.e. S281I in the extracellular domain, I568T in the second extracellular loop of the transmembrane domain and A623I in the third intracellular loop of the transmembrane domain).

Comparison of the Effect of 5C9 and a Mouse TSHR Blocking Monoclonal Antibody 9D33 and the Mixture of the Two Antibodies on TSH Mediated Stimulation of Cyclic AMP Production in CHO Cells Expressing the Wild Type TSHR

The human TSHR blocking MAb 5C9 and the mouse TSHR blocking MAb 9D33 at concentrations as low as 1 μg/mL have the ability to block TSHR cyclic AMP stimulating activity of TSH in CHO-TSHR cells as shown in previous experiments and in Table 12. The effects of the 9D33 IgG and 5C9 IgG on TSH mediated stimulation of cyclic AMP were additive as shown in Table 12; Experiments 1-5). The same additive effect was observed when two different concentrations of TSH (3 ng/mL and 0.3 ng/mL) were used for stimulation (Table 12; Experiments 1-3 and Experiments 4 and 5, respectively).

Comparison of the Effect of 5C9 and a Mouse TSHR Blocking Monoclonal Antibody 9D33 and the Mixture of the Two Antibodies on M22 Mediated Stimulation of Cyclic AMP Production in CHO Cells Expressing the Wild Type TSHR

As shown before, 5C9 and 9D33 also are able to inhibit M22 Fab mediated stimulation of cyclic AMP in CHO-TSHR cells. The effects of the 9D33 IgG and 5C9 IgG on M22 mediated stimulation of cyclic AMP were additive (Table 13 Experiments 1-4). The same additive effect was observed when two different concentrations of M22 Fab (3 ng/mL and 0.3 ng/mL) were used for stimulation (Table 13; Experiments 1 and 2 and Experiments 3 and 4, respectively).

The additive effects of 5C9 IgG and 9D33 IgG were similar for both TSH and M22 mediated stimulation of cyclic AMP production (Tables 12 and 13).

Effect of 5C9 on Basal (i.e. Non-Stimulated) Cyclic AMP Activity in CHO Cells Expressing a High Number of Wild Type TSHRs Per Cell

A CHO cell line expressing approximately 5×10⁵ receptors per cell showed higher levels of basal (i.e. non-stimulated) cyclic AMP compared to a standard CHO cell line (expressing approximately 5×10⁴ TSHR per cell) used in previous experiments (for example Tables 9-13) i.e. 47.1±11.7 pmol/mL compared to approximately 1.0 pmol/mL, respectively. The effect of 5C9 IgG and 9D33 IgG on wild type TSHR basal activity was assessed using the cell line expressing a high number of receptors per cell. Incubation with 9D33 IgG and a negative control antibody to GAD (5B3) resulted in 0-5.3% inhibition of basal cyclic AMP activity (Table 14; Experiment 1) indicating that the blocking mouse MAb 9D33 or control MAb have no effect on basal cyclic AMP production in CHO cells expressing the wild type TSHR. However, in the case of 5C9 IgG a clear inhibition of basal cyclic AMP activity was observed (Table 14; Experiment 2) with 0.1 μg/mL and 10 μg/mL causing 45.7% and 74.6% inhibition respectively. In addition, 5C9 Fab and 5C9 F(ab′) were also effective inhibitors of basal cyclic AMP activity in CHO cells expressing a high number of TSHRs per cell (Table 14 experiment 3). For example, 1 μg/mL and 100 μg/mL of 5C9 Fab showed 39% and 61% inhibition of basal cyclic AMP production, respectively compared to 48% inhibition by 5C9 F(ab′) at 100 μg/mL (Table 14 experiment 3).

Effect of Patient Serum TSHR Autoantibodies with Antagonist (i.e. Blocking) Activity on Basal (i.e. Non-Stimulated) Cyclic AMP Activity in CHO Cells Expressing TSHR with Activating Mutation I568T

The basal cyclic AMP production by TSHR I568T cells in the presence of cyclic AMP assay buffer of 20.5±8.7 pmol/mL was essentially unaffected by addition of normal pool sera from healthy blood donors (NPS) or 3 different individual healthy blood donor sera (N1-N3) tested at 1/10 and 1/50 dilution. The basal cyclic AMP production in the presence of NPS and N1-N3 sera showed 0-14% inhibition compared to basal cyclic AMP production in the presence of cyclic AMP assay buffer (Table 15). However, in the presence of 4 different sera with high levels of blocking type TRAbs (B2-B5) 23-89% inhibition of basal cyclic AMP production was observed (Table 15). In the presence of 5C9 IgG (1 μg/mL), 83% inhibition of TSHR I568T basal cyclic AMP activity was observed. The dose response effect of 2 blocking sera (B3 and B4) on basal cyclic AMP production in CHO cells expressing TSHR with I568T mutation is also shown in Table 15.

These results indicate that 5C9 has the TSHR blocking activity characteristic of patient blocking TSHR autoantibodies in particular with respect to inhibition of basal cyclic AMP production in the TSHR activating mutant I568T.

Effect of Patient Serum TSHR Autoantibodies with Antagonist Activity on Basal (i.e. Non-Stimulated) Cyclic AMP Activity in CHO Cells Expressing TSHR with Activating Mutation S281I

The basal cyclic AMP production by TSHR S281I cells in the presence of cyclic AMP assay buffer was 11.2±2.0 pmol/mL and incubation with healthy blood donor pool sera or individual healthy blood donor sera (diluted 1/10 or 1/50) had no effect (Table 16). In contrast, in the presence of 4 different sera with high levels of blocking type of TRAbs (B2-B5) 31-56% inhibition of basal cyclic AMP production was observed (Table 16). 5C9 IgG at 1 μg/mL caused 71% inhibition of basal cyclic AMP activity in the experiments with TSHR S281I.

Effect of Patient Serum TSHR Autoantibodies with Antagonist Activity on Basal (i.e. Non-Stimulated) Cyclic AMP Activity in CHO Cells Expressing TSHR with Activating Mutation A623I

The basal cyclic AMP production in the case of TSHR A623I cells was 43.5±11.2 pmol/mL in the presence of cyclic AMP assay buffer and was essentially unaffected by incubation with healthy blood donor pool or individual sera (Table 17). Incubation with four different sera with high levels of blocking type of TRAbs (B2-B5) caused—1% to 56% inhibition of cyclic AMP in these experiments (Table 17). This can be compared with 49% inhibition by 5C9 IgG at 1 μg/mL in the same experiment.

Effect of Patient Serum TSHR Autoantibodies with Antagonist Activity on Basal (i.e. Non-Stimulated) Cyclic AMP Activity in CHO Cells Expressing Approximately 5×10⁵ Wild Type TSHRs Per Cell

The basal cyclic AMP production in CHO cells expressing higher number of wild type TSHRs per cell was 28.1±0.7 pmol/mL in this series of experiments. When the cells were incubated with healthy blood donor pool or individual sera (N1-N3) at 1/10 dilutions basal cyclic AMP levels ranged between 99% and 146% of cyclic AMP levels in the presence of cyclic AMP assay buffer while at 1/50 dilutions the range was from 93% to 137%. Out of 4 sera with blocking type TSHR autoantibodies tested, one serum (B2) had no effect on basal cyclic AMP production (Table 18). In the case of two sera (B3 and B5) the levels of cyclic AMP increased relative to the levels observed in the presence of cyclic AMP assay buffer (Table 18). It may well be that sera B3 and B5 contain a mixture of TSHR autoantibodies with stimulating and blocking activities. In contrast, serum B4 had a clear inhibiting effect on basal cyclic AMP production at 1/10 and 1/50 dilution i.e. 31% and 61% respectively of basal cyclic AMP levels relative to the levels in the presence of cyclic AMP assay buffer (Table 18). This can be compared to the levels in the presence of 5C9 IgG at 1 μg/mL of 33% relative to the levels in the presence of cyclic AMP assay buffer (Table 18).

Overall 5C9 IgG shows similar effects on basal cyclic AMP production in CHO cells transfected with wild type TSHR or with TSHR with activating mutations to the effects observed with sera from patients positive for blocking type TSHR autoantibodies. However, the effect of individual patient sera varies in the case of different mutations (Table 19). In the case of wild type TSHR some sera show a stimulating effect presumably due to the presence of TSHR stimulating autoantibodies as well as blocking autoantibodies (Table 19).

Effect of 5C9 on Stimulation of Cyclic AMP Production in CHO Cells Expressing TSHRs Containing Amino Acid Mutations

The effect of 5C9 on stimulation of cyclic AMP production in CHO cells expressing TSHRs with amino acid mutations was extended to include the following mutations to alanine: Asp43, Glu61, His105, Glu107, Phe130, Glu178, Tyr185, Asp203, Tyr206, Lys209, Asp232, Lys250, Glu251, Thr257, Arg274, Asp276 (Table 20 a-p and summarised in Table 21).

Mutation of TSHR amino acids Asp43, Glu61, His105, Glu107, Tyr185, Asp232 and Thr275 to alanine had no effect on 5C9 IgG's ability to inhibit TSH stimulated cyclic AMP production. The ability of 5C9 to inhibit TSH stimulated cyclic AMP production was reduced by mutation of TSHR Phe130, Glu178, Asp203, Tyr206, Lys250, Glu251 and Asp276 to alanine. In the case of 2 mutations Lys209Ala and Asp274Ala, the ability of 5C9 IgG to inhibit TSH mediated cyclic AMP production was enhanced.

In summary (Tables 7, 20 and 21), 10 TSHR residues Lys129, Phe130, Asp151, Glu178, Lys183, Asp203, Tyr206, Lys250, Glu251 and Asp276 all reduced the ability of 5C9 to inhibit cyclic AMP stimulation by TSH compared to the wild type TSHR. Mutation of TSHR Lys129 and Asp203 showed the greatest effect and caused complete inhibition of 5C9 activity.

Effect of Blocking Sera B2-B5 on TSH Mediated Stimulation of Cyclic AMP Production in CHO Cells Expressing Wild Type TSHR Compared to Mutated TSHR Asp203Ala

The blocking effect at 1 μg/mL 5C9 on the wild type TSHR (92% inhibition of TSH induced cyclic AMP stimulation) was reduced to 4% in the case of TSHR Asp203Ala mutation (Table 22).

Blocking serum B4 activity was unaffected by TSHR Asp203Ala mutation while a slight reduction in percent inhibition of TSH induced cyclic AMP stimulation was seen with blocking sera B2 and B3 in the case of TSHR Asp203Ala compared to the wild type TSHR.

In the case of one serum B5, a marked reduction in percent inhibition of TSH induced cyclic AMP stimulation was observed; i.e. 69% inhibition compared to 30% inhibition in wild type and mutated TSHR respectively.

The effect of TSHR Asp203Ala mutation on 5C9 activity was greater than the effect on the activity of blocking sera, however the blocking activity of 3/4 sera tested was affected to varying degrees. This may indicate that the binding sites for blocking TSHR autoantibodies and 5C9 overlap but there are some differences in the actual TSHR amino acids in contact with different sera.

SUMMARY AND CONCLUSIONS

The experiments described above provide evidence that an antibody in accordance with the invention such as 5C9 is able to block stimulating activity of different thyroid stimulators, including human and mouse TSHR stimulating antibodies, native human and animal TSH and recombinant human TSH. Furthermore, evidence is provided that two different blocking type antibodies, i.e. a human MAb 5C9 and a mouse MAb 9D33 that, when tested individually, have the ability to block TSH or M22 meditated stimulation of cyclic AMP in CHO cells expressing the TSHR, show additive blocking effect on TSH or M22 stimulation when mixed together.

Antibodies in accordance with the invention such as 5C9 have a novel effect on the TSHR basal (i.e. non-stimulated) cyclic AMP activity. These effects have been studied by experiments using TSHR transfected CHO cells having higher levels of basal cyclic AMP i.e. the blocking effect of antibodies in accordance with the invention, such as 5C9, on basal cyclic AMP activity has been confirmed. Furthermore, it has been shown that some sera with TSHR autoantibodies with blocking (antagonist) activity have the ability to block basal cyclic AMP activity in these TSHR transfected cells. The experiments also provide evidence of the blocking effect of antibodies in accordance with the invention, such as 5C9, and serum TSHR blocking autoantibodies on basal cyclic AMP activity associated with activating TSHR mutations.

These results emphasise that 5C9 is a human MAb showing the characteristics of blocking type TSHR autoantibodies i.e. that it is representative of patient serum TSHR autoantibodies associated with autoimmune thyroid disease.

The experiments described also allowed identification of some of the TSHR amino acids important for the blocking activity of antibodies in accordance with the invention.

Overall, the results indicate that antibodies in accordance with the invention, such as 5C9, show similar TSHR binding activity and similar biological effects on TSHR function as TSHR blocking autoantibodies found in different sera from patients with autoimmune thyroid disease. Consequently, having characteristics and biological activity of serum blocking TSHR autoantibodies, antibodies in accordance with the invention, such as 5C9, have applications for inactivation of the TSHR in various clinical conditions. These conditions include TSHR activation mediated by TSH, TSHR activation mediated by thyroid stimulating TSHR autoantibodies, basal (non-stimulated, constitutive) TSHR activity and TSHR activation associated with activating TSHR mutations. Consequently, antibodies in accordance with the invention, such as 5C9 have applications for management and control of the conditions associated with TSHR activation mentioned above; for example Graves' disease, Graves' ophthalmopathy, hyperthyroidism due to TSHR activating mutations, hyperthyroidism due to abnormal levels of TSH (pathological or pharmacological), thyroid cancer and thyroid cancer metastases.

TABLE 1 Inhibition of binding of ¹²⁵I-TSH, ¹²⁵I-M22 IgG or ¹²⁵I-5C9 IgG to TSHR coated tubes by 5C9 IgG, lymphocyte donor IgG and lymphocyte donor plasma ¹²⁵I-TSH ¹²⁵I-M22 IgG ¹²⁵I-5C9 Sample (% inhibition) (% inhibition) (% inhibition) Donor plasma (diluted in HBD pool) 1/5  97 92 93 1/10 95 91 92 1/20 82 85 82 1/40 57 75 56 1/80 30 53 29  1/160 16 29 13  1/320 8 13 10 Donor IgG (diluted in 1 mg/mL HBD pool IgG) 1 mg/mL 94 89 91 0.5 mg/mL 90 86 89 0.25 mg/mL 63 79 64 0.1 mg/mL 29 51 26 0.05 mg/mL 13 29 15 0.025 mg/mL 2 17 5 0.01 mg/mL 5 9 1 5C9 IgG (diluted in 100 μg/mL 2G4) 100 μg/mL 84 85 88 50 μg/mL 76 81 80 25 μg/mL 67 69 71 10 μg/mL 54 60 59 5 μg/mL 47 53 54 2.5 μg/mL 42 43 49 1 μg/mL 37 31 42 0.5 μg/mL 33 32 41 0.1 μg/mL 29 22 34 0.05 μg/mL 25 19 30 0.01 μg/mL 13 9 15 0.005 μg/mL 12 5 11 0.001 μg/mL 3 2 3 Average % binding of labelled tracer to TSHR coated tubes was: 14% in the experiments with ¹²⁵I-TSH; 21% in the experiments with ¹²⁵I-M22 IgG and 20% in the experiments with ¹²⁵I-5C9 HBD pool = pool of healthy blood donor sera 2G4 = control IgG (human MAb to thyroid peroxidase).

TABLE 2a Effect of 5C9 IgG or lymphocyte donor serum IgG on TSH stimulation of cyclic AMP production in CHO cells expressing human TSHR Cyclic AMP (fmol/cell well; mean ± SD, Sample IgG concentration n = 3) pTSH (3 ng/mL) only 19020 ± 2154 5C9 IgG only 1 μg/mL 141 ± 5  5C9 IgG + pTSH (3 ng/mL) 1 μg/mL 2208 ± 329 5C9 IgG + pTSH (3 ng/mL) 0.5 μg/mL 4754 ± 876 5C9 IgG + pTSH (3 ng/mL) 0.1 μg/mL 11874 ± 4214 5C9 IgG + pTSH (3 ng/mL) 0.08 μg/mL 14525 ± 3690 5C9 IgG + pTSH (3 ng/mL) 0.06 μg/mL 13290¹ 5C9 IgG + pTSH (3 ng/mL) 0.04 μg/mL 13928 ± 1572 5C9 IgG + pTSH (3 ng/mL) 0.02 μg/mL 16432 ± 9286 5C9 IgG + pTSH (3 ng/mL) 0.01 μg/mL 18969 ± 5308 Cyclic AMP assay buffer only 207 ± 51 Donor serum^(a) 1/10 1.43 mg/mL^(b) 1102 ± 46  Donor serum 1/10 + pTSH (3 ng/mL) 1.43 mg/mL 5931 ± 350 Donor serum 1/20 + pTSH (3 ng/mL) 0.715 mg/mL 16886 ± 728  Donor serum 1/30 + pTSH (3 ng/mL) 0.477 mg/mL 16453 ± 3455 Donor serum 1/40 + pTSH (3 ng/mL) 0.358 mg/mL 17716 ± 1753 Donor serum 1/50 + pTSH (3 ng/mL) 0.286 mg/mL 17928 ± 4772 Donor serum 1/100 + pTSH 0.143 mg/mL 18226 ± 2268 (3 ng/mL) ¹single determination ^(a)Donor serum was diluted in cyclic AMP assay buffer as indicated ^(b)IgG concentration of undiluted serum determined by nephelometry was 14.3 mg/mL 5C9 IgG and TSH were diluted in cyclic AMP assay buffer.

TABLE 2b Inhibition of TSH induced cyclic AMP production in CHO cells expressing TSHR by 5C9 IgG, F(ab′)₂ and Fab fragments Cyclic AMP Sample (fmol/cell well; mean ± SD, n = 3) Example 1 Cyclic AMP assay buffer only  586 ± 148 TSH 3 ng/mL only 18557 ± 363  5C9 Fab 100 μg/mL only 235 ± 35 5C9 Fab 100 μg/mL + TSH 938 ± 93 5C9 Fab 10 μg/mL + TSH 1283 ± 239 5C9 F(ab′)₂ 100 μg/mL only 204 ± 12 5C9 F(ab′)₂ 100 μg/mL + TSH  877 ± 195 5C9 F(ab′)₂ 10 μg/mL + TSH  916 ± 188 5C9 IgG 100 μg/mL only 237 ± 54 5C9 IgG 100 μg/mL + TSH  754 ± 177 5C9 IgG 10 μg/mL + TSH  247 ± 115 2G4 IgG 100 μg/mL + TSH 6082¹ Example 2 Cyclic AMP assay buffer only  584 ± 111 TSH 3 ng/mL only 19363 ± 5198 2G4 IgG 100 μg/mL only  608 ± 169 2G4 IgG 100 μg/mL + TSH 18147 ± 972  2G4 IgG 10 μg/mL + TSH 18114 ± 6544 5C9 F(ab′)₂ 100 μg/mL only 414 ± 22 5C9 F(ab′)₂ 100 μg/mL + TSH 1058 ± 223 5C9 F(ab′)₂ 10 μg/mL + TSH 1333 ± 443 5C9 IgG 100 μg/mL only  338 ± 108 5C9 IgG 100 μg/mL + TSH 1109 ± 375 5C9 IgG 10 μg/mL + TSH 723 ± 71 5C9 Fab 100 μg/mL only 212 ± 37 5C9 Fab 100 μg/mL + TSH  867 ± 127 5C9 Fab 10 μg/mL + TSH 4131 ± 776 ¹mean of duplicate samples 2G4 = control IgG (human MAb to thyroid peroxidase). Antibody and TSH preparations were diluted in cyclic AMP assay buffer.

TABLE 2c Effect of 5C9 IgG and 9D33 IgG on stimulation of cyclic AMP production in CHO cells expressing human TSHR by TSH or M22 Fab Cyclic AMP production (fmol/cell well; Test sample mean ± SD n = 3) Cyclic AMP assay buffer only 473 ± 21 pTSH 3 ng/mL only 12,270 ± 980   5C9 IgG 100 μg/mL only 426 ± 27 5C9 IgG 10 μg/mL only 360 ± 53 5C9 IgG 1 μg/mL only 376 ± 18 5C9 IgG 0.1 μg/mL only 404 ± 42 5C9 IgG 0.01 μg/mL only 578 ± 65 5C9 IgG 0.001 μg/mL only 554 ± 47 5C9 IgG 100 μg/mL + pTSH 3 ng/mL 1094 ± 70  5C9 IgG 10 μg/mL + pTSH 3 ng/mL 1028 ± 47  5C9 IgG 1 μg/mL + pTSH 3 ng/mL 1872 ± 168 5C9 IgG 0.1 μg/mL + pTSH 3 ng/mL 3920 ± 464 5C9 IgG 0.01 μg/mL + pTSH 3 ng/mL 15,050 ± 386   5C9 IgG 0.001 μg/mL + pTSH 3 ng/mL 14,147 ± 1,310 9D33 IgG 100 μg/mL only  626 ± 127 9D33 IgG 100 μg/mL + pTSH 3 ng/mL 2,218 ± 5   M22 Fab 3 ng/mL only 9,432 ± 822  5C9 IgG 100 μg/mL + M22 Fab 3 ng/mL 354 ± 56 5C9 IgG 10 μg/mL + M22 Fab 3 ng/mL  638¹ ± 190 5C9 IgG 1 μg/mL + M22 Fab 3 ng/mL  956 ± 169 5C9 IgG 0.1 μg/mL + M22 Fab 3 ng/mL 1,298 ± 134  5C9 IgG 0.01 μg/mL + M22 Fab 3 ng/mL 9,978 ± 919  5C9 IgG 0.001 μg/mL + M22 Fab 3 ng/mL 11,614 ± 393   9D33 IgG 100 μg/mL + M22 Fab 3 ng/mL 1,048 ± 10   ¹mean of duplicate samples 9D33 is a mouse antibody which blocks both TSH and TRAb mediated stimulation of cyclic AMP production in CHO cells expressing the TSHR. Antibody and TSH preparations were diluted in cyclic AMP assay buffer.

TABLE 3 Binding of ¹²⁵I-5C9 IgG, ¹²⁵I-TSH and ¹²⁵I-M22 IgG binding to TSHR coated tubes and inhibition by patient serum samples ¹²⁵I-5C9 ¹²⁵I-TSH ¹²⁵I-M22 Serum binding binding binding sample inhibition (%) inhibition (%) inhibition (%) N1 15.7 0 9.3 N2 3.3 1.2 7.2 N3 15.3 1.9 0.7 N4 4.0 4.2 0 N5 18.9 6.3 11.4 N6 5.9 2.9 1.4 N7 17.1 7.2 9.4 N8 5.5 0 0 N9 11.2 4.2 2.9 N10 10.5 6.5 5.8 G1 79.6 83.6 80.5 G2 75.8 77.5 73.5 G3 82.2 77.5 78.1 G4 77.7 74.9 74.8 G5 77.0 73.6 71.5 G6 64.7 71.6 69.1 G7 75.6 74.3 66.0 G8 73.7 74.7 77 G9 76.1 78.5 79.2 G10 75.9 75.8 69.9 G11 81.6 82.5 79.7 G12 71.6 76.6 73.9 G13 72.3 71.1 70.2 G14 81.9 85.8 80.9 G15 84.9 85.3 84.4 G16 80.5 84.9 81.7 G17 85.0 86.9 85.3 G18 84.9 85 84.2 G19 85.1 87.3 85.4 G20 84.4 89.3 87.7 G21 77.6 84.9 77.0 G22 67.1 59.7 61.5 G23 57.5 62.2 59.5 G24 65.7 67.1 64.4 G25 59.3 56.3 62.3 G26 38.4 67.7 69.4 G27 22.0 59.1 58.9 G28 68.3 69.7 72.8 G29 40.9 54.2 50.4 G30 71.2 69.1 72 G31 62.2 59.2 62.0 G32 46.0 40.6 49.2 G33 44.0 25.9 37.2 G34 52.0 48 55.0 G35 60.1 54.4 60.7 G36 29.3 31.4 43.2 G37 49.0 44.1 45.5 G38 40.1 26.7 29.8 G39 66.4 54.7 58.9 G40 48.8 48.5 48.5 N1-10 = sera from healthy blood donors G1-G40 = sera from patients with a history of Graves' disease Results are means of closely agreeing duplicate determinations ${\%\mspace{14mu}{inhibition}}\mspace{11mu} = {100 - \left( {\frac{A}{B} \times 100} \right)}$ where A = binding in the presence of test serum; B = binding in the presence of a pool of healthy blood donor serum (HBD pool). ¹²⁵I-5C9 in presence of HBD pool gave 20% binding, ¹²⁵I-TSH in presence of HBD pool gave 12% binding and ¹²⁵I-M22 in presence of HBD pool gave 17% binding.

TABLE 4a Comparison of the inhibition of ¹²⁵I-5C9 IgG, ¹²⁵I-TSH and ¹²⁵I-M22 IgG, binding to TSHR coated tubes by patient serum with either blocking or stimulating activity ¹²⁵I-5C9 ¹²⁵I-TSH ¹²⁵I-M22 binding binding binding Test samples inhibition (%) inhibition (%) inhibition (%) Assay calibrators 40 U/L 87 90 84.4  8 U/L 62 67 63.0  2 U/L 15 27 25.6  1 U/L 4.3 15 14.8 Positive control serum 34 35 38.7 Blocking sera B1 1/5 93 95 91.7 1/10 92 94 89.2 1/20 91 91 85.9 1/40 85 80 78.8 1/80 67 55 67.4 1/160 33 33 45.9 1/320 20 17 26.4 B2 1/5 92 91 86.6 1/10 85 85 79.5 1/20 NT 73 66.2 1/40 68 51 50.0 1/80 42 34 29.7 1/160 19 22 20.3 1/320 NT 13 7.8 B3 1/5 89 93 85.5 1/10 82 84 76.3 1/20 62 64 61.7 1/40 37 44 42.5 1/80 14 26 26.2 1/160 NT 12 16.6 1/320 NT 7 8.9 B4 1/5 93 94 90.3 1/10 93 95 88.5 1/20 92 93 85.1 1/40 89 89 81.1 1/80 78 76 72.1 1/160 56 54 56.9 1/320 34 37 39.9 B5 1/5 94 93 90.3 1/10 91 92 87.0 1/20 87 87 82.2 1/40 74 72 71.7 1/80 56 47 54.6 1/160 31 29 36.4 1/320 19 17 21.4 Stimulating serum S1 1/5 89 91 84.9 1/10 80 84 75.4 1/20 63 67 62.9 1/40 42 50 46.2 1/80 26 34 31.9 1/160 9 21 16.3 1/320 16 4 10.6

TABLE 4b ¹²⁵I-5C9 ¹²⁵I-TSH ¹²⁵I-M22 binding binding binding Test samples inhibition (%) inhibition (%) inhibition (%) Assay calibrators 40 U/L 87.2 90.4 82.2  8 U/L 62.0 67.2 63.3  2 U/L 21.3 22.0 27.9  1 U/L 15.0 13.0 21.8 Positive control 34.2 31.4 38.6 serum HBD pool 6.2 −0.6 12.5 S2 Neat 91.8 95.1 88.6 1/5 76.7 84.5 72.7 1/10 62.3 71.4 66.4 1/20 48.2 57.0 51.9 1/40 31.8 39.3 41.4 1/80 21.3 19.4 32.9 1/160 16.8 9.7 25.1 S4 Neat 91.0 92.9 86.2 1/5 71.0 72.4 68.7 1/10 55.5 55.6 57.4 1/20 39.9 34.0 46.3 1/40 27.3 16.4 35.4 1/80 17.0 8.6 25.4 1/160 16.1 2.1 19.5 B1-B5 are patient sera with high levels of TRAb with antagonist (blocking) activity. B3 is serum from the lymphocyte donor for 5C9 S1, S2 and S4 are patient sera with high levels of TRAb with agonist (stimulating) activity Assay calibrators 40 U/L, 8 U/L, 2 U/L and 1 U/L are dilutions of M22 IgG in a pool of healthy blood donor sera (HBD pool) with activities in U/L of NIBSC 90/672 assessed by inhibition of labelled TSH binding to TSHR coated tubes. ${\%\mspace{14mu}{inhibition}}\mspace{11mu} = {100 - \left( {\frac{A}{B} \times 100} \right)}$ where A = test sample; B = HBD pool NT = not tested 1/5, 1/10 etc indicate dilution factor of test sera in HBD pool, neat = undiluted serum

In the presence of the HBD pool approximately 20%, 17% and 12% of the ¹²⁵I-labelled M22 IgG, 5C9 IgG and TSH respectively bound to the TSHR coated tubes.

TABLE 5 Inhibition of ¹²⁵I-labelled TSH, ¹²⁵I-M22 IgG and ¹²⁵I-5C9 IgG binding to TSHR coated tubes by different concentrations of mouse MAbs to the TSHR ¹²⁵I-TSH ¹²⁵I-M22 IgG ¹²⁵I-5C9 IgG Test sample (% inhib) (% inhib) (% inhib) 5C9 IgG 100 μg/mL 50 53 65.5 5C9 IgG 10 μg/mL 30 22 42 5C9 IgG 1 μg/mL 21 14 27 5C9 IgG 0.1 μg/mL 8 6 10 5C9 IgG 0.01 μg/mL 2 5 0 7C71 IgG¹ 100 μg/mL 65 68 82 7C71 IgG 10 μg/mL 55 64 65 7C71 IgG 1 μg/mL 47 58 53 7C71 IgG 0.1 μg/mL 28 37 17 7C71 IgG 0.01 μg/mL 8 14 5 10C31 IgG¹ 100 μg/mL 68 69 76 10C31 IgG 10 μg/mL 56 71 62 10C31 IgG 1 μg/mL 52 62 54 10C31 IgG 0.1 μg/mL 39 48 36 10C31 IgG 0.01 μg/mL 15 24 8 2E71 IgG¹ 100 μg/mL 51 63 60 2E71 IgG 10 μg/mL 41 62 52 2E71 IgG 1 μg/mL 35.5 59 48 2E71 IgG 0.1 μg/mL 30 43 32 2E71 IgG 0.01 μg/mL 14.5 15 17.5 3E71 IgG¹ 100 μg/mL 49 51 65 3E71 IgG 10 μg/mL 37 51 50 3E71 IgG 1 μg/mL 37 45 40 3E71 IgG 0.1 μg/mL 21.5 28 21 3E71 IgG 0.01 μg/mL 12 15 3 14D3 IgG¹ 100 μg/mL 57 62 63 14D3 IgG 10 μg/mL 52 60 50.5 14D3 IgG 1 μg/mL 37 37 35 14D3 IgG 0.1 μg/mL 12.5 15 10 14D3 IgG 0.01 μg/mL 4 3 1 16E5 IgG¹ 100 μg/mL 48 53 59 16E5 IgG 10 μg/mL 44 51 53 16E5 IgG 1 μg/mL 39 40 47 16E5 IgG 0.1 μg/mL 26 22 34 16E5 IgG 0.01 μg/mL 9 12 20 17D2 IgG¹ 100 μg/mL 56 49 55 17D2 IgG 10 μg/mL 43 39 43 17D2 IgG 1 μg/mL 24 24 26 17D2 IgG 0.1 μg/mL 7 13 11 17D2 IgG 0.01 μg/mL 3 1 3 M22 IgG 100 μg/mL 95 95 88 M22 IgG 10 μg/mL 95 94 89 M22 IgG 1 μg/mL 94 93 87 M22 IgG 0.1 μg/mL 77 79 72 M22 IgG 0.01 μg/mL 22 32 24 9D33 IgG² 100 μg/mL 69 61 70 9D33 IgG 10 μg/mL 65 60 60 9D33 IgG 1 μg/mL 55 48 48 9D33 IgG 0.1 μg/mL 31 27 29 9D33 IgG 0.01 μg/mL 8 13 13 2G4 IgG³ 100 μg/mL 3 3 6 2G4 IgG 10 μg/mL 3 4 10 2G4 IgG 1 μg/mL 0 0 8 2G4 IgG 0.1 μg/mL 4 6 4 2G4 IgG 0.01 μg/mL 0 0 0 2B4 IgG⁴ 100 μg/mL 88.5 30 72 2B4 IgG 10 μg/mL 85 19 48 2B4 IgG 1 μg/mL 82 9 42 2B4 IgG 0.1 μg/mL 56 12 23 2B4 IgG 0.01 μg/mL 13.5 1 8 8E3 IgG⁴ 100 μg/mL 82.5 27 65 8E3 IgG 10 μg/mL 72 18 42 8E3 IgG 1 μg/mL 53 8 23 8E3 IgG 0.1 μg/mL 17 0.5 9 8E3 IgG 0.01 μg/mL 5 0 0 4E2 IgG⁴ 100 μg/mL 76 24 32 4E2 IgG 10 μg/mL 74 21 32 4E2 IgG 1 μg/mL 57 15 20 4E2 IgG 0.1 μg/mL 25 2 11 4E2 IgG 0.01 μg/mL 4 1 5 1D5 IgG⁴ 100 μg/mL 77 26 26 1D5 IgG 10 μg/mL 72 20 20 1D5 IgG 1 μg/mL 55 8 13 1D5 IgG 0.1 μg/mL 23 0 3 1D5 IgG 0.01 μg/mL 4 0 0 7C4 IgG⁴ 100 μg/mL 78 24 51 7C4 IgG 10 μg/mL 76 22 35 7C4 IgG 1 μg/mL 72 22 36 7C4 IgG 0.1 μg/mL 38 7 19 7C4 IgG 0.01 μg/mL 9 6 6 3E6 IgG⁴ 100 μg/mL 84 46 55 3E6 IgG 10 μg/mL 79 31 40 3E6 IgG 1 μg/mL 71 16 29 3E6 IgG 0.1 μg/mL 28 5 9 3E6 IgG 0.01 μg/mL 3 0 6 1C52 IgG⁴ 100 μg/mL 64 22 30 1C52 IgG 10 μg/mL 39 9 15 1C52 IgG 1 μg/mL 22 5 15 1C52 IgG 0.1 μg/mL 5 4 11 1C52 IgG 0.01 μg/mL 0 2 10 7B72 IgG⁴ 100 μg/mL 88 32 39 7B72 IgG 10 μg/mL 77 21 27 7B72 IgG 1 μg/mL 50 14 22 7B72 IgG 0.1 μg/mL 16 2 13 7B72 IgG 0.01 μg/mL 8 1 4 8E2 IgG⁵ 100 μg/mL 52 52 32 8E2 IgG 10 μg/mL 24.5 24 12 8E2 IgG 1 μg/mL 8 3 1 8E2 IgG 0.1 μg/mL 13 1 8 8E2 IgG 0.01 μg/mL 0 0 13 18C5 IgG⁶ 100 μg/mL 57 50 51 18C5 IgG 10 μg/mL 17 14 24 18C5 IgG 1 μg/mL 3.5 2 17 18C5 IgG 0.1 μg/mL 3 0 13 18C5 IgG 0.01 μg/mL 0.7 0 14 2G2 IgG⁷ 100 μg/mL 0.1 0 11 2G2 IgG 10 μg/mL 3 0.6 10 2G2 IgG 1 μg/mL 6 1.5 12 2G2 IgG 0.1 μg/mL 2 0.2 9 2G2 IgG 0.01 μg/mL 2 1.4 11 Antibodies were diluted in a pool of healthy blood donor sera (HBD pool). ${\%\mspace{14mu}{inhibition}}\mspace{11mu} = {100 - \left( {\frac{A}{B} \times 100} \right)}$ where A = % binding in the presence of test sample; B = % binding in the presence of HBD pool. ¹mouse TSHR MAb with thyroid stimulating activity ²mouse TSHR MAb which blocks both TSH and TRAb mediated stimulation of cyclic AMP production (see Table 2) ³human MAb to thyroid peroxidase MAb (negative control) ⁴mouse TSHR MAb with TSH blocking activity (recognises an epitope formed by TSHR amino acids 381-385) ⁵mouse TSHR MAb with TSH blocking activity (recognises an epitope formed by TSHR amino acids 36-42) ⁶mouse TSHR MAb with TSH blocking activity (recognises an epitope formed by TSHR amino acids 246-260) ⁷mouse Tg MAb (negative control)

In the presence of HBD pool, approximately 13%, 24% and 15% of ¹²⁵I-labelled 5C9 IgG, M22 IgG and TSH respectively bound to the TSHR coated tubes.

TABLE 6a Effect of 5C9 IgG on stimulation of cyclic AMP production in CHO cells expressing human TSHR by TRAb in patient sera Test sample Cyclic AMP (fmol/cell well mean ± SD; n = 3) Experiment 1a Cyclic AMP assay buffer 378 ± 21 only HBD pool only 352 ± 38 HBD pool + 2G4 IgG 316 ± 54 HBD pool + 5C9 IgG 136 ± 46 T1 only 13734 ± 580  T1 + 2G4 IgG 10928 ± 740  T1 + 5C9 IgG 142 ± 4  T2 only 1716 ± 185 T2 + 2G4 IgG 1362 ± 190 T2 + 5C9 IgG 146 ± 4  T3 only 11722 ± 1280 T3 + 2G4 IgG 11948 ± 3200 T3 + 5C9 IgG 5660 ± 790 T4 only 6388 ± 820 T4 + 2G4 IgG 6022 ± 710 T4 + 5C9 IgG 188 ± 65 T5 only 3084 ± 990 T5 + 2G4 IgG 2152 ± 240 T5 + 5C9 IgG 152 ± 15 T6 only 14802 ± 1475 T6 + 2G4 IgG 10878 ± 675  T6 + 5C9 IgG 232 ± 25 Experiment 1b Cyclic AMP assay buffer 434 ± 52 only HBD pool only  518 ± 216 HBD pool + 2G4 IgG 378 ± 34 HBD pool + 5C9 IgG 178 ± 47 T7 only  7388 ± 1250 T7 + 2G4 IgG 5696 ± 715 T7 + 5C9 IgG ud T8 only 1736¹ T8 + 2G4 IgG 1392¹ T8 + 5C9 IgG ud T9 only 5052¹ T9 + 2G4 IgG 5000¹ T9 + 5C9 IgG ud Experiment 1c Cyclic AMP assay buffer  366 ± 316 only HBD pool only 646 ± 62 HBD pool + 2G4 IgG 496 ± 42 HBD pool + 5C9 IgG 294 ± 92 T13 only  4030 ± 1146 T13 + 2G4 IgG 3330 ± 63  T13 + 5C9 IgG 540 ± 36 T14 only 5490 ± 197 T14 + 2G4 IgG  4470 ± 1867 T14 + 5C9 IgG  510 ± 146 T15 only 2130 ± 387 T15 + 2G4 IgG 2380 ± 320 T15 + 5C9 IgG ud T16 only 4990 ± 155 T16 + 2G4 IgG 5270 ± 941 T16 + 5C9 IgG ud T17 only 4410 ± 470 T17 + 2G4 IgG 4460 ± 288 T17 + 5C9 IgG ud T18 only  910 ± 126 T18 + 2G4 IgG 830 ± 21 T18 + 5C9 IgG ud Experiment 1d Cyclic AMP assay buffer 487 ± 75 only HBD pool only 285 ± 71 HBD pool + 2G4 IgG 311 ± 68 HBD pool + 5C9 IgG 108 ± 33 T11 only 4052 ± 233 T11 + 2G4 IgG  4659 ± 1260 T11 + 5C9 IgG 154 ± 33 T12 only 4058 ± 721 T12 + 2G4 IgG 5556 ± 593 T12 + 5C9 IgG 145 ± 24 ud = undetectable ¹= duplicate determination HBD pool is a pool of healthy blood donor serum; 1:10 dilution in cyclic AMP assay buffer was used in these experiments. T1-T9 and T11-T18 are sera which stimulate cyclic AMP production in CHO cells expressing the TSHR. T1-T9 and T11-T18 were tested diluted 1:10 in cyclic AMP assay buffer 2G4 is a human monoclonal antibody to thyroid peroxidase (negative control). 2G4 IgG and 5C9 IgG were tested at 100 μg/mL.

TABLE 6b Dose response effects of 5C9 IgG and 9D33 IgG on stimulation of cyclic AMP production in CHO cells expressing human TSHR by TRAb in patient sera Experiment 2 Cyclic AMP (fmol/cell Test samples well mean ± SD; n = 3) Cyclic AMP assay buffer only  707 ± 147 HBD pool only 503 ± 80 T1 only 20336 ± 1539 100 μg/mL 2G4 IgG 1207 ± 123 (negative control IgG) only T1 + 100 μg/mL 2G4 IgG 22078 ± 2546 T1 + 10 μg/mL 2G4 IgG 18868 ± 1806 T1 + 1 μg/mL 2G4 IgG 19025 ± 1450 T1 + 0.1 μg/mL 2G4 IgG 16659 ± 1031 T1 + 0.01 μg/mL 2G4 IgG 20876 ± 1887 T1 + 0.001 μg/mL 2G4 IgG 18134 ± 2126 100 μg/mL 9D33 IgG only  721 ± 183 T1 + 100 μg/mL 9D33 IgG 1061 ± 104 T1 + 10 μg/mL 9D33 IgG 1464 ± 191 T1 + 1 μg/mL 9D33 IgG  4990 ± 1670 T1 + 0.1 μg/mL 9D33 IgG 17867 ± 2220 T1 + 0.01 μg/mL 9D33 IgG 19943 ± 1834 T1 + 0.001 μg/mL 9D33 IgG 21648 ± 502  100 μg/mL 5C9 IgG only 301 ± 38 T1 + 100 μg/mL 5C9 IgG 724 ± 28 T1 + 10 μg/mL 5C9 IgG 1119 ± 348 T1 + 1 μg/mL 5C9 IgG 2428 ± 594 T1 + 0.1 μg/mL 5C9 IgG 16152 ± 3577 T1 + 0.01 μg/mL 5C9 IgG 20314 ± 279  T1 + 0.001 μg/mL 5C9 IgG 16868 ± 912  T1 is a patient serum sample which stimulates cyclic AMP production in CHO cells expressing the TSHR; 1:10 dilution in cyclic AMP assay buffer was used in these experiments. 2G4 is a human monoclonal antibody to thyroid peroxidase (negative control). 9D33 is a mouse monoclonal antibody to the TSHR which blocks both TSH and TRAb stimulated cyclic AMP production (see Table 2).

TABLE 6c Dose response effects of 5C9 IgG on stimulation of cyclic AMP production in CHO cells expressing human TSHR by patient sera TRAb Experiment 3 Cyclic AMP (fmol/cell Test samples well mean ± SD; n = 3) Cyclic AMP assay buffer only  757 ± 138 HBD pool only 512 ± 76 T6 only 14216 ± 3985 100 μg/mL 9D33 IgG only 729 ± 31 T6 + 100 μg/mL 9D33 IgG 1052 ± 702 T6 + 10 μg/mL 9D33 IgG  2256 ± 1088 T6 + 1 μg/mL 9D33 IgG 5447 ± 313 T6 + 0.1 μg/mL 9D33 IgG 8700 ± 665 T6 + 0.01 μg/mL 9D33 IgG 10290 ± 495  T6 + 0.001 μg/mL 9D33 IgG 10296¹ 100 μg/mL 5C9 IgG only 360 ± 38 T6 + 100 μg/mL 5C9 IgG 295 ± 30 T6 + 10 μg/mL 5C9 IgG 1027 ± 368 T6 + 1 μg/mL 5C9 IgG 2368 ± 528 T6 + 0.1 μg/mL 5C9 IgG  9533 ± 1679 T6 + 0.01 μg/mL 5C9 IgG 13883 ± 1718 T6 + 0.001 μg/mL 5C9 IgG 11843 ± 1241 ¹single determination See Tables 6a and 6b for explanatory footnotes.

TABLE 6d Dose response effects of 5C9 IgG on stimulation of cyclic AMP production in CHO cells expressing human TSHR by TRAb in patient sera Cyclic AMP (fmol/cell Sample well mean ± SD; n = 3) Cyclic AMP assay buffer only 622 ± 79 HBD pool only 479 ± 53 T3 only 14023 ± 2487 100 μg/mL 2G4 IgG only  745 ± 136 T3 + 100 μg/mL 2G4 IgG 12086 ± 2613 T3 + 10 μg/mL 2G4 IgG 12862 ± 250  T3 + 1 μg/mL 2G4 IgG 12931 ± 891  T3 + 0.1 μg/mL 2G4 IgG 13853 ± 1589 T3 + 0.01 μg/mL 2G4 IgG 11939 ± 131  T3 + 0.001 μg/mL 2G4 IgG 13650 ± 1679 100 μg/mL 9D33 IgG only  616 ± 111 T3 + 100 μg/mL 9D33 IgG 1597 ± 323 T3 + 10 μg/mL 9D33 IgG 4262 ± 367 T3 + 1 μg/mL 9D33 IgG 7385 ± 554 T3 + 0.1 μg/mL 9D33 IgG 11960 ± 1390 T3 + 0.01 μg/mL 9D33 IgG 12178 ± 1676 T3 + 0.001 μg/mL 9D33 IgG 12159 ± 2970 100 μg/mL 5C9 IgG only 212 ± 40 T3 + 100 μg/mL 5C9 IgG 6136 ± 558 T3 + 10 μg/mL 5C9 IgG 7806 ± 793 T3 + 1 μg/mL 5C9 IgG 8075 ± 610 T3 + 0.1 μg/mL 5C9 IgG 10414 ± 1094 T3 + 0.01 μg/mL 5C9 IgG 13743 ± 1687 T3 + 0.001 μg/mL 5C9 IgG 11641 ± 2168 See Tables 6a and 6b for explanatory footnotes.

TABLE 6e Dose response effects of 5C9 IgG on stimulation of cyclic AMP production in CHO cells expressing human TSHR by TRAb patient sera Cyclic AMP (fmol/cell Sample well mean ± SD; n = 3) Cyclic AMP assay buffer only  616 ± 161 HBD pool only 312 ± 56 T19 only 6014 ± 280 100 μg/mL 2G4 IgG only 1058 ± 75  T19 + 100 μg/mL 2G4 IgG 7142 ± 215 T19 + 10 μg/mL 2G4 IgG 6182 ± 46  T19 + 1 μg/mL 2G4 IgG  7280 ± 1052 T19 + 0.1 μg/mL 2G4 IgG 7275 ± 145 T19 + 0.01 μg/mL 2G4 IgG 6820 ± 729 T19 + 0.001 μg/mL 2G4 IgG 7620 ± 870 100 μg/mL 9D33 IgG only  592 ± 168 T19 + 100 μg/mL 9D33 IgG 550 ± 65 T19 + 10 μg/mL 9D33 IgG 448 ± 76 T19 + 1 μg/mL 9D33 IgG 404 ± 36 T19 + 0.1 μg/mL 9D33 IgG 2394¹ T19 + 0.01 μg/mL 9D33 IgG 5765¹ T19 + 0.001 μg/mL 9D33 IgG 7088 ± 668 100 μg/mL 5C9 IgG only  186² T19 + 100 μg/mL 5C9 IgG 220 ± 90 T19 + 10 μg/mL 5C9 IgG  275 ± 150 T19 + 1 μg/mL 5C9 IgG 187 ± 34 T19 + 0.1 μg/mL 5C9 IgG  375 ± 129 T19 + 0.01 μg/mL 5C9 IgG 5747 ± 411 T19 + 0.001 μg/mL 5C9 IgG 6467¹ ¹mean of duplicate sample ²single determination See Tables 6a and 6b for explanatory footnotes.

TABLE 6f Dose response effects of 5C9 IgG on stimulation of cyclic AMP production in CHO cells expressing human TSHR by TRAb in patient sera Cyclic AMP (fmol/cell Sample well mean ± SD; n = 3) Cyclic AMP assay buffer only 255 ± 40 HBD pool only 200 ± 82 T20 only 4764 ± 732 100 μg/mL 2G4 IgG only 835 ± 94 T20 + 100 μg/mL 2G4 IgG 6684 ± 931 T20 + 10 μg/mL 2G4 IgG 4571 ± 776 T20 + 1 μg/mL 2G4 IgG 5744 ± 727 T20 + 0.1 μg/mL 2G4 IgG 4323 ± 849 T20 + 0.01 μg/mL 2G4 IgG  6396 ± 1314 T20 + 0.001 μg/mL 2G4 IgG 6789 ± 893 100 μg/mL 9D33 IgG only  382 ± 142 T20 + 100 μg/mL 9D33 IgG  287 ± 164 T20 + 10 μg/mL 9D33 IgG 204 ± 49 T20 + 1 μg/mL 9D33 IgG 980¹ T20 + 0.1 μg/mL 9D33 IgG 5362 ± 574 T20 + 0.01 μg/mL 9D33 IgG  5389 ± 1139 T20 + 0.001 μg/mL 9D33 IgG 7514 ± 785 100 μg/mL 5C9 IgG only  224 ± 109 T20 + 100 μg/mL 5C9 IgG NT T20 + 10 μg/mL 5C9 IgG NT T20 + 1 μg/mL 5C9 IgG 181¹ T20 + 0.1 μg/mL 5C9 IgG  2184 ± 1078 T20 + 0.01 μg/mL 5C9 IgG 6486 ± 436 T20 + 0.001 μg/mL 5C9 IgG 4856¹  ¹mean of duplicate sample NT = not tested See Tables 6a and 6b for explanatory footnotes.

TABLE 6g Dose response effects of 5C9 IgG on stimulation of cyclic AMP production in CHO cells expressing human TSHR by TRAb in patient sera Cyclic AMP (fmol/cell well Sample mean ± SD; n = 3) Cyclic AMP assay buffer only 466 ± 65  HBD pool only 390 ± 118 T21 only 9781 ± 1672 100 μg/mL 2G4 IgG only 999 ± 55  T21 + 100 μg/mL 2G4 IgG 10848 ± 373  T21 + 10 μg/mL 2G4 IgG 10355 ± 469  T21 + 1 μg/mL 2G4 IgG 10831 ± 140  T21 + 0.1 μg/mL 2G4 IgG 12215 ± 793  T21 + 0.01 μg/mL 2G4 IgG 13014 ± 855  T21 + 0.001 μg/mL 2G4 IgG 10500 ± 162  100 μg/mL 9D33 IgG only 534 ± 89  T21 + 100 μg/mL 9D33 IgG 442 ± 32  T21 + 10 μg/mL 9D33 IgG 605 ± 254 T21 + 1 μg/mL 9D33 IgG 1383 ± 66  T21 + 0.1 μg/mL 9D33 IgG 8719 ± 389  T21 + 0.01 μg/mL 9D33 IgG 10772 ± 799  T21 + 0.001 μg/mL 9D33 IgG 10229 ± 714  100 μg/mL 5C9 IgG only 253 ± 25  T21 + 100 μg/mL 5C9 IgG 210 ± 60  T21 + 10 μg/mL 5C9 IgG 303 ± 107 T21 + 1 μg/mL 5C9 IgG 418 ± 65  T21 + 0.1 μg/mL 5C9 IgG 7483 ± 415  T21 + 0.01 μg/mL 5C9 IgG 10441 ± 122  T21 + 0.001 μg/mL 5C9 IgG 11281 ± 911  See Tables 6a and 6b for explanatory footnotes.

TABLE 7a TSH induced cyclic AMP production in CHO cells expressing wild type TSHR and TSHR with Lys58 mutated to Alanine. Effect of different dilutions of 5C9 IgG Cyclic AMP produced (fmol/cell well; mean ± SD, n = 3) Mutated/ Wild type Mutated wild type Test sample TSHR TSHR (%) Cyclic AMP assay buffer only 315 ± 39  822 ± 52  260 TSH only 10730 ± 1737  13228 ± 1428  123 2G4 10 μg/mL + TSH 11707 ± 2291  12883 ± 2107  110 2G4 100 μg/mL + TSH 9640 ± 1664 10148 ± 3680  105 5C9 0.01 μg/mL + TSH 7341 ± 343  7913 ± 880  108 5C9 0.1 μg/mL + TSH 4635 ± 257  4815¹ 104 5C9 1.0 μg/mL + TSH 918 ± 159 1794 ± 308  195 5C9 10 μg/mL + TSH 351 ± 187 955 ± 405 272 5C9 100 μg/mL + TSH 528 ± 363 1001 ± 306  190 5C9 100 μg/mL only 47 ± 15 <25 — ¹mean of duplicate determinations pTSH concentration = 3 ng/mL All dilutions in cyclic AMP assay buffer 2G4 is a human monoclonal antibody to thyroid peroxidase (negative control for 5C9).

TABLE 7b TSH induced cyclic AMP production in CHO cells expressing wild type TSHR and TSHR with Ile60 mutated to Alanine. Effect of different dilutions of 5C9 IgG Cyclic AMP produced (fmol/cell well; mean ± SD, n = 3) Mutated/ Wild type Mutated wild type Test sample TSHR TSHR (%) Cyclic AMP assay buffer only 470 ± 92  837 ± 78  114 TSH only 18654¹ 22935 ± 2542  123 2G4 10 μg/mL + TSH 17555¹ 22960 ± 4312  131 2G4 100 μg/mL + TSH 18654 ± 3979  24488 ± 4501  131 5C9 0.01 μg/mL + TSH 8018 ± 276  18952 ± 1811  236 5C9 0.1 μg/mL + TSH 7097 ± 613  11609 ± 1415  164 5C9 1.0 μg/mL + TSH 1568 ± 133  3290 ± 64  210 5C9 10 μg/mL + TSH 1772 ± 632  1211 ± 343   68 5C9 100 μg/mL + TSH 1733 ± 132  3134 ± 794  181 5C9 100 μg/mL only 61 ± 8  260 ± 43  426 See Table 7a for explanatory footnotes.

TABLE 7c TSH induced cyclic AMP production in CHO cells expressing wild type TSHR and TSHR with Arg80 mutated to Alanine. Effect of different dilutions of 5C9 IgG Cyclic AMP produced (fmol/cell well; mean ± SD, n = 3) Mutated/ Wild type Mutated wild type Test sample TSHR TSHR (%) Cyclic AMP assay buffer only 775 ± 66  1165 ± 32  150 TSH only 12467 ± 510  12930 ± 179  104 2G4 10 μg/mL + TSH 13600 ± 1555  14849 ± 462  109 2G4 100 μg/mL + TSH 11726 ± 177  13539 ± 314  115 5C9 0.01 μg/mL + TSH 14410 ± 1331  14273 ± 1845   99 5C9 0.1 μg/mL + TSH 11256 ± 1627  9278 ± 837   82 5C9 1.0 μg/mL + TSH 6704 ± 791  1358 ± 500   20 5C9 10 μg/mL + TSH 2107 ± 264  1163 ± 415   55 5C9 100 μg/mL + TSH 2234 ± 540  518 ± 133  23 5C9 100 μg/mL only 244 ± 92  494 ± 163 202 See Table 7a for explanatory footnotes.

TABLE 7d TSH induced cyclic AMP production in CHO cells expressing wild type TSHR and TSHR with Arg80 mutated to Aspartic acid. Effect of different dilutions of 5C9 IgG Cyclic AMP produced (fmol/cell well; mean ± SD, n = 3) Mutated/ Wild type Mutated wild type Test sample TSHR TSHR (%) Cyclic AMP assay buffer only 548 ± 67  637 ± 96  116 TSH only 13598 ± 3445  19400 ± 1684  143 2G4 10 μg/mL + TSH 14795 ± 2776  19430 ± 1779  131 2G4 100 μg/mL + TSH 15500 ± 897  16003 ± 237  103 5C9 0.01 μg/mL + TSH 13082¹ 21021 ± 2838  161 5C9 0.1 μg/mL + TSH 6326 ± 358  4420 ± 182   70 5C9 1.0 μg/mL + TSH 2635 ± 326  1912 ± 101   73 5C9 10 μg/mL + TSH 1906 ± 146  1249 ± 329   66 5C9 100 μg/mL + TSH 1613 ± 176  1274 ± 15   79 5C9 100 μg/mL only 300 ± 45  523 ± 3  174 See Table 7a for explanatory footnotes.

TABLE 7e TSH induced cyclic AMP production in CHO cells expressing wild type TSHR and TSHR with Tyr82 mutated to Alanine. Effect of different dilutions of 5C9 IgG Cyclic AMP produced (fmol/cell well; mean ± SD, n = 3) Mutated/ Wild type Mutated wild type Test sample TSHR TSHR (%) Cyclic AMP assay buffer only 557 ± 27  1219 ± 49  219 TSH only 12674 ± 234  15327 ± 2041  121 2G4 10 μg/mL + TSH 13587 ± 967  17585¹ 129 2G4 100 μg/mL + TSH 13518 ± 894  15395 ± 1777  113 5C9 0.01 μg/mL + TSH 13902 ± 1970  15737 ± 1442  113 5C9 0.1 μg/mL + TSH 6250 ± 1143 12692 ± 3138  203 5C9 1.0 μg/mL + TSH 1600 ± 467  2955 ± 732  185 5C9 10 μg/mL + TSH 822 ± 99  1646 ± 308  200 5C9 100 μg/mL + TSH 978 ± 102 1028 ± 216  105 5C9 100 μg/mL only 289 ± 30  1427 ± 419  494 See Table 7a for explanatory footnotes.

TABLE 7f TSH induced cyclic AMP production in CHO cells expressing wild type TSHR and TSHR with Thr104 mutated to Alanine. Effect of different dilutions of 5C9 IgG Cyclic AMP produced (fmol/cell well; mean ± SD, n = 3) Mutated/ Wild type Mutated wild type Test sample TSHR TSHR (%) Cyclic AMP assay buffer only 590 ± 59  640 ± 95  108 TSH only 11294 ± 1307  14247 ± 3093  126 2G4 10 μg/mL + TSH 14255 ± 1410  13227 ± 1782   93 2G4 100 μg/mL + TSH 13422 ± 2337  15499 ± 2042  115 5C9 0.01 μg/mL + TSH 12307 ± 1080  11733 ± 422   95 5C9 0.1 μg/mL + TSH 7097 ± 79  9506 ± 738  134 5C9 1.0 μg/mL + TSH 3699 ± 391  6196 ± 1075 168 5C9 10 μg/mL + TSH 1796 ± 417  3094 ± 740  172 5C9 100 μg/mL + TSH 2218 ± 395  3110 ± 412  140 5C9 100 μg/mL only 195 ± 23  264 ± 102 135 See Table 7a for explanatory footnotes.

TABLE 7g TSH induced cyclic AMP production in CHO cells expressing wild type TSHR and TSHR with Arg109 mutated to Alanine. Effect of different dilutions of 5C9 IgG Cyclic AMP produced Mutated/ (fmol/cell well; mean ± SD, n = 3) wild type Test sample Wild type TSHR Mutated TSHR (%) Cyclic AMP assay buffer 381 ± 28 675 ± 50  177 only TSH only 13823 ± 5141 9769 ± 372  71 2G4 10 μg/mL + TSH 14428 ± 8959 9524 ± 1014 66 2G4 100 μg/mL + TSH 19307 ± 3130 8800 ± 631  46 5C9 0.01 μg/mL + TSH 10820 ± 1644 9651 ± 1066 89 5C9 0.1 μg/mL + TSH  4011 ± 1290 1719 ± 40  43 5C9 1.0 μg/mL + TSH 1206 ± 88  827 ± 157 69 5C9 10 μg/mL + TSH  706 ± 282 827 ± 147 117 5C9 100 μg/mL + TSH 1230 ± 120 561 ± 164 46 5C9 100 μg/mL only 228 ± 45 335 ± 14  147 See Table 7a for explanatory footnotes.

TABLE 7h TSH induced cyclic AMP production in CHO cells expressing wild type TSHR and TSHR with Lys129 mutated to Alanine. Effect of different dilutions of 5C9 IgG Cyclic AMP produced (fmol/cell well; mean ± SD, n = 3) Mutated/ Wild type Mutated wild type Test sample TSHR TSHR (%) Cyclic AMP assay buffer only 370 ± 97  590 ± 17  159 TSH only 15632 ± 2362  15502 ± 547  99 2G4 10 μg/mL + TSH 11344 ± 3278  14787 ± 986  130 2G4 100 μg/mL + TSH 12580 ± 2397  14148 ± 1033  112 5C9 0.01 μg/mL + TSH 10545 ± 161  12161 ± 1797  115 5C9 0.1 μg/mL + TSH 2714 ± 154  13257 ± 2414  488 5C9 1.0 μg/mL + TSH 1008 ± 229  12837 ± 1148  1274 5C9 10 μg/mL + TSH 548 ± 26  11175¹ 2039 5C9 100 μg/mL + TSH 491 ± 73  15929 ± 1228  3244 5C9 100 μg/mL only 107 ± 18  217 ± 36  203 See Table 7a for explanatory footnotes.

TABLE 7i TSH induced cyclic AMP production in CHO cells expressing wild type TSHR and TSHR with Phe134 mutated to Alanine. Effect of different dilutions of 5C9 IgG Cyclic AMP produced (fmol/cell well; mean ± SD, n = 3) Mutated/ Wild type Mutated wild type Test sample TSHR TSHR (%) Cyclic AMP assay buffer only 347 ± 88  867 ± 129 250 TSH only 17641 ± 2133  15497 ± 1691  88 2G4 10 μg/mL + TSH 13759 ± 116  17235 ± 1602  125 2G4 100 μg/mL + TSH 11224 ± 4039  16213 ± 1948  144 5C9 0.01 μg/mL + TSH 13584 ± 1268  15872 ± 1140  117 5C9 0.1 μg/mL + TSH 8702 ± 1542 6368 ± 778  73 5C9 1.0 μg/mL + TSH 4542 ± 104  1944 ± 838  43 5C9 10 μg/mL + TSH 2394 ± 44  1058 ± 189  44 5C9 100 μg/mL + TSH 1393 ± 128  1069 ± 65  77 5C9 100 μg/mL only 212 ± 6  337 ± 60  159 See Table 7a for explanatory footnotes.

TABLE 7j TSH induced cyclic AMP production in CHO cells expressing wild type TSHR and TSHR with Asp151 mutated to Alanine. Effect of different dilutions of 5C9 IgG Cyclic AMP produced (fmol/cell well; mean ± SD, n = 3) Mutated/ Wild type Mutated wild type Test sample TSHR TSHR (%) Cyclic AMP assay buffer only 508 ± 341 1236 ± 88  243 TSH only 11266 ± 76   10455 ± 771   93 2G4 10 μg/mL + TSH 15208 ± 1686  10713 ± 1859   70 2G4 100 μg/mL + TSH 11915 ± 1366  10416 ± 3434  114 5C9 0.01 μg/mL + TSH 11245 ± 1583  12616 ± 1295  112 5C9 0.1 μg/mL + TSH 6949 ± 99  9956 ± 983  143 5C9 1.0 μg/mL + TSH 1388 ± 238  6450 ± 2088 465 5C9 10 μg/mL + TSH 380 ± 108 2276 ± 1238 599 5C9 100 μg/mL + TSH 945 ± 180 1535 ± 378  162 5C9 100 μg/mL only 176 ± 49  395 ± 42  224 See Table 7a for explanatory footnotes.

TABLE 7k TSH induced cyclic AMP production in CHO cells expressing wild type TSHR and TSHR with Asp151 mutated to Arginine. Effect of different dilutions of 5C9 IgG Cyclic AMP produced (fmol/cell well; mean ± SD, n = 3) Mutated/ Wild type Mutated wild type Test sample TSHR TSHR (%) Cyclic AMP assay buffer only 703 ± 107 768 ± 82  109 TSH only 11131 ± 3208  19990 ± 458  180 2G4 10 μg/mL + TSH 15927 ± 2244  18846 ± 3293  118 2G4 100 μg/mL + TSH 13643 ± 3195  21275 ± 1580  156 5C9 0.01 μg/mL + TSH 12351 ± 5559  18254 ± 1877  148 5C9 0.1 μg/mL + TSH 6694 ± 3111 10561 ± 1025  158 5C9 1.0 μg/mL + TSH 2754 ± 166  2591 ± 472   94 5C9 10 μg/mL + TSH 1217¹ 1609 ± 69  132 5C9 100 μg/mL + TSH 1572 ± 515  2330 ± 273  148 5C9 100 μg/mL only 260 ± 156 409 ± 88  157 See Table 7a for explanatory footnotes.

TABLE 7l M22 induced cyclic AMP production in CHO cells expressing wild type TSHR and TSHR with Asp160 mutated to Lysine. Effect of different dilutions of 5C9 IgG Cyclic AMP produced (fmol/cell well; mean ± SD, n = 3) Mutated/ Wild type Mutated wild type Test sample TSHR TSHR (%) Cyclic AMP assay buffer only 787 ± 119 1252 ± 274  159 M22 only 16750 ± 1515  14288 ± 1260   85 2G4 10 μg/mL + M22 16188 ± 1463  15476 ± 468   96 2G4 100 μg/mL + M22 15505 ± 2665  12638 ± 819   82 5C9 0.01 μg/mL + M22 16719 ± 541  15239 ± 445   91 5C9 0.1 μg/mL + M22 9385 ± 4006 7704 ± 703   82 5C9 1.0 μg/mL + M22 821 ± 268 963 ± 204 117 5C9 10 μg/mL + M22 208 ± 89  642 ± 386 309 5C9 100 μg/mL + M22 301 ± 182 657 ± 87  218 5C9 100 μg/mL only 429 ± 49  458 ± 8  107 M22 only (repeat 16702 ± 2170  18892 ± 2113  113 determination) M22 concentration = 3 ng/mL See Table 7a for other explanatory footnotes.

TABLE 7m TSH induced cyclic AMP production in CHO cells expressing wild type TSHR and TSHR with Lys183 mutated to Alanine. Effect of different dilutions of 5C9 IgG Cyclic AMP produced (fmol/cell well; mean ± SD, n = 3) Mutated/ Wild type Mutated wild type Test sample TSHR TSHR (%) Cyclic AMP assay buffer only 642 ± 34  1153 ± 236  180 TSH only 22385 ± 532  20210 ± 1366   90 2G4 10 μg/mL + TSH 20148 ± 2625  23254 ± 3027  115 2G4 100 μg/mL + TSH 19926¹ 22442 ± 2489  113 5C9 0.01 μg/mL + TSH 17974¹ 23284 ± 2243  130 5C9 0.1 μg/mL + TSH 11499 ± 892  24289 ± 720  211 5C9 1.0 μg/mL + TSH 3489 ± 606  14586 ± 155  418 5C9 10 μg/mL + TSH 1234 ± 357  7568 ± 605  618 5C9 100 μg/mL + TSH 1456 ± 838  11448 ± 933  786 5C9 100 μg/mL only 384 ± 19  747 ± 230 195 See Table 7a for explanatory footnotes.

TABLE 7n TSH induced cyclic AMP production in CHO cells expressing wild type TSHR and TSHR with Lys183 mutated to Aspartic acid. Effect of different dilutions of 5C9 IgG Cyclic AMP produced (fmol/cell well; mean ± SD, n = 3) Mutated/ Wild type Mutated wild type Test sample TSHR TSHR (%) Cyclic AMP assay buffer only 486 ± 151 737 ± 54  152 TSH only 14730 ± 1647  17668 ± 597  120 2G4 10 μg/mL + TSH 14234 ± 1097  17133 ± 2281  120 2G4 100 μg/mL + TSH 14737 ± 1905  16071 ± 1188  109 5C9 0.01 μg/mL + TSH 12911 ± 2357  20614 ± 2552  160 5C9 0.1 μg/mL + TSH 8577 ± 615  17344 ± 2898  202 5C9 1.0 μg/mL + TSH 3424 ± 135  12655 ± 835  370 5C9 10 μg/mL + TSH 1114 ± 112  6587 ± 1480 591 5C9 100 μg/mL + TSH 1720 ± 119  9007 ± 1295 524 5C9 100 μg/mL only <12.5 54 ± 8  — See Table 7a for explanatory footnotes.

TABLE 7o TSH induced cyclic AMP production in CHO cells expressing wild type TSHR and TSHR with Gln235 mutated to Alanine. Effect of different dilutions of 5C9 IgG Cyclic AMP produced (fmol/cell well; mean ± SD, n = 3) Mutated/ Wild type Mutated wild type Test sample TSHR TSHR (%) Cyclic AMP assay buffer only 478 ± 94  713 ± 52  149 TSH only 14882 ± 944  15844 ± 922  106 2G4 10 μg/mL + TSH 17754 ± 3150  18900 ± 3098  106 2G4 100 μg/mL + TSH 12991¹ 18598 ± 2708  143 5C9 0.01 μg/mL + TSH 7181 ± 618  17535 ± 3692  244 5C9 0.1 μg/mL + TSH 7784 ± 1111 7437 ± 1183  96 5C9 1.0 μg/mL + TSH 2545 ± 471  2416 ± 423   95 5C9 10 μg/mL + TSH 532 ± 65  1023 ± 400  192 5C9 100 μg/mL + TSH 747 ± 114 727 ± 168  97 5C9 100 μg/mL only 119 ± 28  256 ± 86  215 See Table 7a for explanatory footnotes.

TABLE 7p TSH induced cyclic AMP production in CHO cells expressing wild type TSHR and TSHR with Arg255 mutated to Alanine. Effect of different dilutions of 5C9 IgG Cyclic AMP produced Mutated/ (fmol/cell well; mean ± SD, n = 3) wild type Test sample Wild type TSHR Mutated TSHR (%) Cyclic AMP assay buffer 538 ± 12  797 ± 113 148 only TSH only 14362 ± 3305 15243 ± 2093 106 2G4 10 μg/mL + TSH 14444 ± 3161 19042 ± 1085 132 2G4 100 μg/mL + TSH 16810 ± 3461 17710 ± 4886 105 5C9 0.01 μg/mL + TSH  6624 ± 1236 8124 ± 395 123 5C9 0.1 μg/mL + TSH 3788 ± 838 4137 ± 537 109 5C9 1.0 μg/mL + TSH  966 ± 150 1941 ± 113 201 5C9 10 μg/mL + TSH  867 ± 100  692 ± 152 80 5C9 100 μg/mL + TSH 1013 ± 247  809 ± 248 80 5C9 100 μg/mL only 32¹ 248 ± 94 775 See Table 7a for explanatory footnotes.

TABLE 7q TSH induced cyclic AMP production in CHO cells expressing wild type TSHR and TSHR with Arg255 mutated to Aspartic acid. Effect of different dilutions of 5C9 IgG Cyclic AMP produced Mutated/ (fmol/cell well; mean ± SD, n = 3) wild type Test sample Wild type TSHR Mutated TSHR (%) Cyclic AMP assay buffer 620 ± 33 616¹ 99 only TSH only 17531 ± 1730 18081 ± 2439 103 2G4 10 μg/mL + TSH 19870 ± 2766 15519 ± 702  78 2G4 100 μg/mL + TSH 18265 ± 1999 19638 ± 1505 108 5C9 0.01 μg/mL + TSH 17518 ± 2407 15654 ± 148  89 5C9 0.1 μg/mL + TSH  6604 ± 1552 5583 ± 655 85 5C9 1.0 μg/mL + TSH 3375 ± 227 1932 ± 677 57 5C9 10 μg/mL + TSH 1244 ± 565 735 ± 9  59 5C9 100 μg/mL + TSH 1506 ± 151 1414 ± 568 94 5C9 100 μg/mL only  278 ± 125 559 ± 97 201 See Table 7a for explanatory footnotes.

TABLE 7r TSH induced cyclic AMP production in CHO cells expressing wild type TSHR and TSHR with Trp258 mutated to Alanine. Effect of different dilutions of 5C9 IgG Cyclic AMP produced Mutated/ (fmol/cell well; mean ± SD, n = 3) wild type Test sample Wild type TSHR Mutated TSHR (%) Cyclic AMP assay buffer 354 ± 28 382 ± 55 108 only TSH only 21023 ± 2104  7095 ± 1086 33 2G4 10 μg/mL + TSH 19564 ± 1076 7070 ± 148 36 2G4 100 μg/mL + TSH 21591 ± 2652 6066 ± 336 28 5C9 0.01 μg/mL + TSH 19471 ± 1456 6619 ± 511 34 5C9 0.1 μg/mL + TSH 10455 ± 1968 1944 ± 168 19 5C9 1.0 μg/mL + TSH 2616 ± 118 1127 ± 24  43 5C9 10 μg/mL + TSH 1192 ± 253 357 ± 11 30 5C9 100 μg/mL + TSH 1316 ± 283  484 ± 247 37 5C9 100 μg/mL only 211 ± 35  423 ± 109 200 See Table 7a for explanatory footnotes.

TABLE 7s TSH induced cyclic AMP production in CHO cells expressing wild type TSHR and TSHR with Ser281 mutated to Alanine. Effect of different dilutions of 5C9 IgG Cyclic AMP produced Mutated/ (fmol/cell well; mean ± SD, n = 3) wild type Test sample Wild type TSHR Mutated TSHR (%) Cyclic AMP assay buffer 496 ± 72 1094 ± 132 221 only TSH only 13562 ± 3416 26450¹ 195 2G4 10 μg/mL + TSH 16805 ± 1139 25086 ± 1730 149 2G4 100 μg/mL + TSH 14334 ± 860  27672 ± 3549 193 5C9 0.01 μg/mL + TSH 13791 ± 3221 28966 ± 3443 210 5C9 0.1 μg/mL + TSH  9071 ± 1696 15560 ± 5836 172 5C9 1.0 μg/mL + TSH 3732 ± 514 3550 ± 725 95 5C9 10 μg/mL + TSH  802 ± 215 1551 ± 545 193 5C9 100 μg/mL + TSH 1078 ± 158 1601 ± 720 149 5C9 100 μg only 201 ± 41  785 ± 188 391 See Table 7a for explanatory footnotes.

TABLE 8 Comparison of serum TRAb assay results obtained with ELISAs based on inhibition of TSH-biotin binding or 5C9 IgG-biotin binding TSH-biotin reference assay 5C9 IgG-biotin assay Abs % Concentration Abs % Concentration Test samples 450 nm inhibition (U/L) 450 nm inhibition (U/L) Assay negative 2.143 0 0 2.421 0 0 control Assay calibrators 1 U/L 1.821 15 1 2.027 16 1 2 U/L 1.564 27 2 1.747 28 2 8 U/L 0.66 69 8 0.532 78 8 40 U/L 0.132 94 40 0.092 96 40 Assay positive 1.273 41 3.22 1.344 44 3.28 control Patient sera A 2.122 1 0.14 2.209 9 0.44 B 1.081 50 4.24 1.029 58 4.54 C 0.225 90 26.03 0.173 93 18.4 D 2.069 3 0.24 2.27 6 0.31 E 1.789 16 1.12 2.189 10 0.49 F 1.454 32 2.43 1.791 26 1.85 G 1.053 51 4.41 1.123 54 4.12 H 1.242 42 3.37 1.309 46 3.4 I 0.208 90 28.01 0.174 93 18.32 Healthy blood donor sera 4276 2.182 −2 0 2.451 −1 0 4280 2.292 −7 0 2.621 −8 0 4281 2.138 0 0 2.529 −4 0 4282 2.204 −3 0 2.6 −7 0 4284 2.306 −8 0 2.613 −8 0 4285 2.328 −9 0 2.756 −14 0 4286 2.34 −9 0 2.691 −11 0 4289 2.381 −11 0 2.628 −9 0 Assay calibrators 40 U/L, 8 U/L, 2 U/L and 1 U/L are dilutions of M22 IgG in a pool of healthy blood donor sera (HBD pool) with activities in U/L of NIBSC 90/672 assessed by inhibition of labelled TSH binding to TSHR coated tubes. Assay negative control is an HBD pool.

TABLE 9 Effects of 5C9 IgG on TSHR stimulation by thyroid stimulating mouse MAbs (mTSMAbs) Cyclic AMP concentration (mean pmol/mL ± SD; n = 3) in CHO cells expressing wild type TSHR after addition of TSMAb and:- 5C9 IgG 2G4 IgG^(b) Test Sample^(a) Buffer only 100 μg/mL 100 μg/mL TSMAb 1 18.94 ± 7.4  1.24 ± 0.07 16.5 ± 1.1  1 μg/mL TSMAb 2 9.71 ± 0.96 2.26 ± 0.05 8.96 ± 1.28 1 μg/mL TSMAb 4 34.5 ± 2.04 2.20 ± 0.20 33.1 ± 1.25 10 ng/mL TSMAb 5 27.26 ± 2.14  0.85 ± 0.01 22.5 ± 2.4  100 ng/mL TSMAb 7 9.90 ± 1.52 1.26 ± 0.59 9.07 ± 0.65 100 ng/mL Buffer only 3.39 ± 1.35 1.56 ± 1.84 4.32 ± 0.95 ^(a)dilution in cyclic AMP assay buffer ^(b)2G4 is a control human monoclonal autoantibody to thyroid peroxidase.

TABLE 10 Effect of 5C9 IgG on TSHR stimulation by different preparations of TSH Cyclic AMP concentration (pmol/mL mean ± SD; n = 3) Test sample diluted in cyclic AMP in CHO cells assay buffer expressing wild type TSHR Experiment 1 Buffer only 0.37 ± 0.15 Native human TSH 100 ng/mL only 36.14 ± 1.83  Native human TSH 100 ng/mL and 36.0 ± 6.1  0.001 μg/mL 5C9 IgG. Native human TSH 100 ng/mL and 18.0 ± 5.4  0.01 μg/mL 5C9 IgG Native human TSH 100 ng/mL and 0.20 ± 0.06 0.1 μg/mL 5C9 IgG Native human TSH 100 ng/mL and 0.14 ± 0.02 1.0 μg/mL 5C9 IgG Native human TSH 100 ng/mL and 0.11 ± 0.04 10 μg/mL 5C9 IgG Native human TSH 100 ng/mL and 0.16 ± 0.03 100 μg/mL 5C9 IgG Recombinant human TSH 100 ng/mL 12.73 ± 4.0  only Recombinant human TSH 100 ng/mL and 13.63 ± 1.7  0.001 μg/mL 5C9 IgG. Recombinant human TSH 100 ng/mL and 8.13 ± 2.13 0.01 μg/mL 5C9 IgG Recombinant human TSH 100 ng/mL and 0.12 ± 0.06 0.1 μg/mL 5C9 IgG Recombinant human TSH 100 ng/mL and 0.10 ± 0.03 1.0 μg/mL 5C9 IgG Recombinant human TSH 100 ng/mL and 0.12 ± 0.05 10 μg/mL 5C9 IgG Recombinant human TSH 100 ng/mL and 0.19 ± 0.08 100 μg/mL 5C9 IgG Experiment 2 Buffer only 0.18 ± 0.08 Native human TSH 100 ng/mL only 40.8 ± 6.92 Native human TSH 100 ng/mL and 37.6 ± 6.35 0.001 μg/mL 5C9 IgG. Native human TSH 100 ng/mL and 34.4 ± 2.28 0.01 μg/mL 5C9 IgG Native human TSH 100 ng/mL and 15.8 ± 1.39 0.1 μg/mL 5C9 IgG Native human TSH 100 ng/mL and 0.13 ± 0.03 1.0 μg/mL 5C9 IgG Native human TSH 100 ng/mL and 0.18 ± 0.05 10 μg/mL 5C9 IgG Native human TSH 100 ng/mL and 0.21 ± 0.10 100 μg/mL 5C9 IgG Recombinant human TSH 100 ng/mL 16.72 ± 2.90  only Recombinant human TSH 100 ng/mL and 20.0 ± 1.73 0.001 μg/mL 5C9 IgG. Recombinant human TSH 100 ng/mL and 20.6 ± 1.57 0.01 μg/mL 5C9 IgG Recombinant human TSH 100 ng/mL and 7.39 ± 1.74 0.1 μg/mL 5C9 IgG Recombinant human TSH 100 ng/mL and 0.07 ± 0.01 1.0 μg/mL 5C9 IgG Recombinant human TSH 100 ng/mL and 0.07 ± 0.01 10 μg/mL 5C9 IgG Recombinant human TSH 100 ng/mL and 0.11 ± 0.03 100 μg/mL 5C9 IgG Native porcine TSH 0.3 ng/mL only 40.2 ± 4.0  Native porcine TSH 0.3 ng/mL and 32.7 ± 4.0  0.001 μg/mL 5C9 IgG. Native porcine TSH 0.3 ng/mL and 28.2 ± 2.04 0.01 μg/mL 5C9 IgG Native porcine TSH 0.3 ng/mL and 18.0 ± 1.36 0.1 μg/mL 5C9 IgG Native porcine TSH 0.3 ng/mL and 2.14 ± 0.85 1.0 μg/mL 5C9 IgG Native porcine TSH 0.3 ng/mL and 0.20 ± 0.14 10 μg/mL 5C9 IgG Native porcine TSH 0.3 ng/mL and 0.18 ± 0.13 100 μg/mL 5C9 IgG Experiment 3 Buffer only 2.0 ± 0.8 Native human TSH 100 ng/mL only 31.1 ± 2.55 Native human TSH 100 ng/mL and 36.0 ± 3.27 0.001 μg/mL 5C9 IgG. Native human TSH 100 ng/mL and 28.4 ± 3.55 0.01 μg/mL 5C9 IgG Native human TSH 100 ng/mL and 7.22 ± 3.20 0.1 μg/mL 5C9 IgG Native human TSH 100 ng/mL and 0.67 ± 0.46 1.0 μg/mL 5C9 IgG Native human TSH 100 ng/mL and  0.8 ± 0.45 10 μg/mL 5C9 IgG Native human TSH 100 ng/mL and 1.35 ± 1.0  100 μg/mL 5C9 IgG Recombinant human TSH 100 ng/mL 26.4 ± 3.53 only Recombinant human TSH 100 ng/mL and 25.6 ± 2.45 0.001 μg/mL 5C9 IgG. Recombinant human TSH 100 ng/mL and 22.9 ± 7.4  0.01 μg/mL 5C9 IgG Recombinant human TSH 100 ng/mL and 1.18 ± 0.49 0.1 μg/mL 5C9 IgG Recombinant human TSH 100 ng/mL and 0.81 ± 0.05 1.0 μg/mL 5C9 IgG Recombinant human TSH 100 ng/mL and 0.74 ± 0.42 10 μg/mL 5C9 IgG Recombinant human TSH 100 ng/mL and 0.88 ± 0.55 100 μg/mL 5C9 IgG Native porcine TSH 0.3 ng/mL only 35.7 ± 4.82 Native porcine TSH 0.3 ng/mL and 38.2 ± 2.54 0.001 μg/mL 5C9 IgG. Native porcine TSH 0.3 ng/mL and 26.6 ± 3.22 0.01 μg/mL 5C9 IgG Native porcine TSH 0.3 ng/mL and 10.1 ± 1.79 0.1 μg/mL 5C9 IgG Native porcine TSH 0.3 ng/mL and 2.28 ± 0.71 1.0 μg/mL 5C9 IgG Native porcine TSH 0.3 ng/mL and 0.68 ± 0.21 10 μg/mL 5C9 IgG Native porcine TSH 0.3 ng/mL and 1.03 ± 0.63 100 μg/mL 5C9 IgG

TABLE 11a Effects of 5C9 IgG and 9D33 IgG on the constitutive activity of TSHR with an activating mutation S281I Cyclic AMP concentration (pmol/mL Test sample diluted in cyclic AMP mean ± SD; n = 3) in CHO cells assay buffer expressing TSHR S281I Buffer only 9.90 ± 1.51 0.001 μg/mL 2G4 IgG^(a) 6.83 ± 0.37  0.01 μg/mL 2G4 IgG 7.74 ± 0.78  0.1 μg/mL 2G4 IgG 8.58 ± 1.12    1 μg/mL 2G4 IgG 8.37 ± 1.10 0.001 μg/mL 5C9 IgG 4.31 ± 0.16  0.01 μg/mL 5C9 IgG 4.17 ± 0.60  0.1 μg/mL 5C9 IgG 3.20 ± 0.63    1 μg/mL 5C9 IgG 3.44 ± 0.63 0.001 μg/mL 9D33 IgG 5.97 ± 0.94  0.01 μg/mL 9D33 IgG 9.27 ± 1.4  0.1 μg/mL 9D33 IgG 8.13 ± 0.72    1 μg/mL 9D33 IgG 7.33 ± 1.17 ^(a)2G4 is a control human monoclonal antibody to thyroid peroxidase.

TABLE 11b Effect of 5C9 IgG and 9D33 IgG on the constitutive activity of TSHR with an activating mutation I568T Cyclic AMP concentration (pmol/mL Test sample diluted in cyclic AMP mean ± SD; n = 3) in CHO cells assay buffer expressing TSHR I568T Buffer only 21.39 ± 5.31 0.001 μg/mL 2G4 IgG 19.13 ± 2.77  0.01 μg/mL 2G4 IgG 16.67 ± 1.87  0.1 μg/mL 2G4 IgG 19.92 ± 0.91    1 μg/mL 2G4 IgG 20.52 ± 0.95 0.001 μg/mL 5C9 IgG 18.81 ± 1.39  0.01 μg/mL 5C9 IgG  9.24 ± 0.83  0.1 μg/mL 5C9 IgG  6.02 ± 1.93    1 μg/mL 5C9 IgG  5.29 ± 0.75 0.001 μg/mL 9D33 IgG 16.58 ± 0.00  0.01 μg/mL RSR-B2 IgG 17.03 ± 2.36  0.1 μg/mL RSR-B2 IgG 19.96 ± 1.66    1 μg/mL RSR-B2 IgG 21.65 ± 1.99

TABLE 11c Effect of 5C9 IgG and 9D33 IgG on the constitutive activity of TSHR with an activating mutation A623I Cyclic AMP concentration (pmol/mL Test sample diluted in cyclic AMP mean ± SD; n = 3) in CHO cells assay buffer expressing TSHR A623I Buffer only 36.89^(a) 0.001 μg/mL 2G4 IgG 28.46 ± 2.31  0.01 μg/mL 2G4 IgG 33.44 ± 1.12  0.1 μg/mL 2G4 IgG 30.40 ± 7.93    1 μg/mL 2G4 IgG 28.96 ± 2.29 0.001 μg/mL 5C9 IgG 26.52 ± 1.33  0.01 μg/mL 5C9 IgG 27.03 ± 2.13  0.1 μg/mL 5C9 IgG 19.79 ± 0.48    1 μg/mL 5C9 IgG 16.43 ± 1.27 0.001 μg/mL 9D33 IgG 29.55 ± 3.15  0.01 μg/mL 9D33 IgG 27.64 ± 3.49  0.1 μg/mL 9D33 IgG 31.78 ± 9.18    1 μg/mL 9D33 IgG 40.09 ± 7.73 ^(a)duplicate determination

TABLE 12 Effects of 5C9 plus 9D33 on blocking of pTSH stimulation of cyclic AMP production in CHO cells expressing wild type TSHR. Cyclic AMP concentration Test sample in cyclic AMP assay buffer (pmol/mL mean ± SD; n = 3) Experiment 1 Buffer only 1.9 ± 1.0 TSH 3 ng/mL 48.5 ± 14   10 μg/mL 9D33 2.9 ± 1.0 10 μg/mL 5C9 0.45 ± 0.31 10 μg/mL 9D33 + 10 μg/mL 5C9 1.12 ± 0.4  10 μg/mL 9D33 + TSH 23.8 ± 8.7  10 μg/mL 5C9 + TSH 3.7 ± 2.7 10 μg/mL 9D33 + 10 μg/mL 5C9 +  4.9 (n = 2) TSH 1 μg/mL 9D33 + TSH 28.7 ± 1.8  1 μg/mL 5C9 + TSH 13.9 ± 3.1  1 μg/mL 9D33 + 1 μg/mL 5C9 + 12.6 ± 2.5  TSH Experiment 2 Buffer only 0.72 ± 0.63 TSH 3 ng/mL 34.3 ± 3.1  10 μg/mL 9D33 1.6 ± 1.3 10 μg/mL 5C9 0.4 ± 0.4 10 μg/mL 9D33 + 10 μg/mL 5C9 0.03 (n = 1) 10 μg/mL 9D33 + TSH 9.5 ± 1.7 10 μg/mL 5C9 + TSH 3.1 ± 1.0 10 μg/mL 9D33 + 10 μg/mL 5C9 + 3.3 ± 2.0 TSH 1 μg/mL 9D33 + TSH 19.0 ± 3.2  1 μg/mL 5C9 + TSH 6.1 ± 0.6 1 μg/mL 9D33 + 1 μg/mL 5C9 + 5.9 ± 0.6 TSH Experiment 3 Buffer only 0.99 ± 0.03 TSH 3 ng/mL 51.3 ± 5.0  100 μg/mL 9D33 1.14 ± 0.13 100 μg/mL 5C9 0.50 ± 0.04 100 μg/mL 9D33 + 100 μg/mL 5C9 0.66 ± 0.9  100 μg/mL 9D33 + TSH 10.53 ± 0.84  100 μg/mL 5C9 + TSH  1.4 ± 0.18 100 μg/mL 9D33 + 100 μg/mL 5C9 +  1.3 ± 0.36 TSH 10 μg/mL 9D33 + TSH 13.5 ± 2.9  10 μg/mL 5C9 + TSH 1.9 ± 1.1 10 μg/mL 9D33 + 10 μg/mL 5C9 + 1.2 ± 0.1 TSH 1 μg/mL 9D33 + TSH 27.8 ± 2.2  1 μg/mL 5C9 + TSH 5.4 ± 1.8 1 μg/mL 9D33 + 1 μg/mL 5C9 + 5.2 ± 0.3 TSH 0.1 μg/mL 9D33 + TSH 35.1 ± 2.3  0.1 μg/mL 5C9 + TSH 18.7 ± 3.4  0.1 μg/mL 9D33 + 0.1 μg/mL 5C9 + 14.4 ± 1.0  TSH 0.01 μg/mL 9D33 + TSH 47.1 ± 1.9  0.01 μg/mL 5C9 + TSH 33.9 ± 7.8  0.01 μg/mL 9D33 + 0.01 μg/mL 5C9 + 27.8 ± 1.3  TSH Experiment 4 Buffer only 1.4 ± 0.5 TSH 0.3 ng/mL 46.6 ± 12.9 100 μg/mL 9D33 0.99 ± 0.62 100 μg/mL 5C9 0.15 ± 0.12 100 μg/mL 9D33 + 100 μg/mL 5C9 0.41 ± 0.40 100 μg/mL 9D33 + TSH 3.53 ± 1.1  100 μg/mL 5C9 + TSH 0.29 ± 0.15 100 μg/mL 9D33 + 100 μg/mL 5C9 + 0.63 ± 0.38 TSH 10 μg/mL 9D33 + TSH 4.23 ± 0.81 10 μg/mL 5C9 + TSH 0.23 ± 0.08 10 μg/mL 9D33 + 10 μg/mL 5C9 + 0.52 ± 0.15 TSH 1 μg/mL 9D33 + TSH 9.01 ± 0.67 1 μg/mL 5C9 + TSH 1.65 ± 0.47 1 μg/mL 9D33 + 1 μg/mL 5C9 + 1.21 ± 0.67 TSH 0.1 μg/mL 9D33 + TSH 20.2 ± 2.2  0.1 μg/mL 5C9 + TSH 6.2 ± 1.8 0.1 μg/mL 9D33 + 0.1 μg/mL 5C9 + 7.6 ± 1.3 TSH Experiment 5 Buffer only 1.83 ± 0.64 TSH 0.3 ng/mL 17.26 ± 1.5  10 μg/mL 9D33 2.07 ± 0.52 10 μg/mL 5C9 0.38 ± 0.2  10 μg/mL 9D33 + 10 μg/mL 5C9 0.96 ± 0.14 10 μg/mL 9D33 + TSH 3.57 ± 0.58 10 μg/mL 5C9 + TSH 1.17 ± 0.00 10 μg/mL 9D33 + 10 μg/mL 5C9 + 1.58 ± 0.20 TSH 5 μg/mL 9D33 + TSH 3.71 ± 0.10 5 μg/mL 5C9 + TSH 1.21 ± 0.36 1 μg/mL 9D33 + TSH 6.38 ± 1.35 1 μg/mL 5C9 + TSH 2.57 ± 0.65 1 μg/mL 9D33 + 1 μg/mL 5C9 + 1.46 ± 0.59 TSH 0.1 μg/mL 9D33 + TSH 14.67 ± 4.69  0.1 μg/mL 5C9 + TSH 12.43 ± 1.59  0.1 μg/mL 9D33 + 0.1 μg/mL 5C9 + 9.99 ± 3.78 TSH

TABLE 13 Effect of 5C9 plus 9D33 on blocking of M22 Fab mediated stimulation of cyclic AMP production in CHO cells expressing wild type TSHR Cyclic AMP concentration Test sample in cyclic AMP assay buffer (pmol/mL mean ± SD; n = 3) Experiment 1 Buffer only 1.45 ± 0.46 M22 3 ng/mL 49.1 ± 9.8 100 μg/mL 9D33 1.51 ± 0.22 100 μg/mL 5C9 0.35 ± 0.30 100 μg/mL 9D33 + 100 μg/mL 5C9 1.57 ± 0.13 100 μg/mL 9D33 + M22 2.13 ± 0.74 100 μg/mL 5C9 + M22 0.35 ± 0.08 100 μg/mL 9D33 + 100 μg/mL 5C9 + 0.70 ± 0.40 M22 10 μg/mL 9D33 + M22  2.5 ± 0.8 10 μg/mL 5C9 + M22 0.36 ± 0.25 10 μg/mL 9D33 + 10 μg/mL 5C9 + M22 0.52 ± 0.12 1 μg/mL 9D33 + M22 5.25 ± 0.55 1 μg/mL 5C9 + M22 0.93 ± 0.07 1 μg/mL 9D33 + 1 μg/mL 5C9 + M22 0.69 ± 0.13 0.1 μg/mL 9D33 + M22 27.6 ± 2.5 0.1 μg/mL 5C9 + M22  6.0 ± 2.6 0.1 μg/mL 9D33 + 0.1 μg/mL 5C9 + 13.7 ± 7.5 M22 0.01 μg/mL 9D33 + M22 47.5 ± 4.5 0.01 μg/mL 5C9 + M22 48.1 ± 5.4 0.01 μg/mL 9D33 + 0.01 μg/mL 5C9 ± 47.5 ± 4.5 M22 Experiment 2 Buffer only 1.69 ± 0.47 M22 3 ng/mL 68.3 ± 6.3 100 μg/mL 9D33 1.76 ± 0.43 100 μg/mL 5C9 0.69 ± 0.18 100 μg/mL 9D33 + 100 μg/mL 5C9 1.16 ± 0.35 100 μg/mL 9D33 + M22 1.42 ± 1.20 100 μg/mL 5C9 + M22 undetectable 100 μg/mL 9D33 + 100 μg/mL 5C9 ± 0.14 (n = 2) M22 10 μg/mL 9D33 + M22 0.67 (n = 2) 10 μg/mL 5C9 + M22 0.14 (n = 1) 10 μg/mL 9D33 + 10 μg/mL 5C9 + M22 2.41 (n = 1) 1 μg/mL 9D33 + M22 6.03 ± 1.15 1 mg/mL 5C9 + M22 2.54 (n = 1) 1 μg/mL 9D33 + 1 μg/mL 5C9 + M22 1.51 (n = 1) 0.1 μg/mL 9D33 + M22 38.7 ± 8.1 0.1 μg/mL 5C9 + M22 4.17 ± 1.7 0.1 μg/mL 9D33 + 0.1 μg/mL 5C9 + 5.17 ± 2.85 M22 0.01 μg/mL 9D33 + M22 60.2 ± 8.0 0.01 μg/mL 5C9 + M22 57.3 ± 13.7 0.01 μg/mL 9D33 + 0.01 μg/mL 5C9 + 40.4 ± 5.3 M22 0.001 μg/mL 9D33 + M22 79.1 ± 26.3 0.001 μg/mL 5C9 + M22 63.3 ± 19.0 0.001 μg/mL 9D33 + 0.001 μg/mL 5C9 + 40.2 ± 8.7 M22 Experiment 3 Buffer only 0.86 ± 0.12 M22 0.3 ng/mL 21.8 ± 3.23 100 μg/mL 9D33 0.88 ± 0.30 100 μg/mL 5C9 0.58 ± 0.28 100 μg/mL 9D33 + 100 μg/mL 5C9 0.81 ± 0.36 100 μg/mL 9D33 + M22 1.03 ± 0.32 100 μg/mL 5C9 + M22 0.05 (n = 2) 100 μg/mL 9D33 + 100 μg/mL 5C9 + 0.06 (n = 2) M22 10 μg/mL 9D33 + M22 0.97 ± 0.48 10 μg/mL 5C9 + M22 0.20 (n = 2) 10 μg/mL 9D33 + 10 μg/mL 5C9 + M22 0.14 ± 0.08 1 μg/mL 9D33 + M22 0.83 ± 0.21 1 μg/mL 5C9 + M22 0.02 (n = 2) 1 μg/mL 9D33 + 1 μg/mL 5C9 + M22 0.13 ± 0.13 0.1 μg/mL 9D33 + M22 5.38 ± 1.71 0.1 μg/mL 5C9 + M22 1.43 ± 1.09 0.1 μg/mL 9D33 + 0.1 μg/mL 5C9 + 2.39 ± 1.0 M22 0.01 μg/mL 9D33 + M22 15.2 ± 1.42 0.01 μg/mL 5C9 + M22 13.1 ± 1.34 0.01 μg/mL 9D33 + 0.01 μg/mL 5C9 + 12.7 ± 3.4 M22 0.001 μg/mL 9D33 + M22 12.8 ± 1.60 0.001 μg/mL 5C9 + M22 13.3 ± 0.89 0.001 μg/mL 9D33 + 0.001 μg/mL 5C9 + 15.8 ± 2.15 M22 Experiment 4 Buffer only 1.29 ± 0.68 M22 0.3 ng/mL 31.1 ± 9.4 100 μg/mL 9D33 2.38 ± 1.11 100 μg/mL 5C9 0.12 ± 0.09 100 μg/mL 9D33 + 100 μg/mL 5C9 0.81 ± 0.15 100 μg/mL 9D33 + M22 2.00 ± 0.87 100 μg/mL 5C9 + M22 0.22 ± 0.11 100 μg/mL 9D33 + 100 μg/mL 5C9 + 0.40 ± 0.18 M22 10 μg/mL 9D33 + M22 1.25 ± 0.09 10 μg/mL 5C9 + M22 0.40 ± 0.17 10 μg/mL 9D33 + 10 μg/mL 5C9 + M22 0.45 ± 0.31 1 μg/mL 9D33 + M22 2.66 ± 0.64 1 μg/mL 5C9 + M22 0.21 ± 0.18 1 μg/mL 9D33 + 1 μg/mL 5C9 + M22 0.14 ± 0.07 0.1 μg/mL 9D33 + M22 27.6 ± 2.5 0.1 μg/mL 5C9 + M22  6.0 ± 2.6 0.1 μg/mL 9D33 + 0.1 μg/mL 5C9 + M22  7.2 ± 3.9 0.01 μg/mL 9D33 + M22 38.9 ± 6.4 0.01 μg/mL 5C9 + M22 31.5 ± 4.0 0.01 μg/mL 9D33 + 0.01 μg/mL 5C9 + 20.6 ± 5.3 M22 0.001 μg/mL 9D33 + M22 43.2 ± 7.9 0.001 μg/mL 5C9 + M22 33.1 ± 4.0 0.001 μg/mL 9D33 + 0.001 μg/mL 5C9 + 25.3 ± 6.0 M22

TABLE 14 Effect of 5C9 and 9D33 IgG on basal cyclic AMP production in CHO cells expressing wild type TSHR (approximately 5 × 10⁵ receptors per cell) Experiment 1 Cyclic AMP concentration % Inhibition of basal pmol/mL cyclic AMP Test Sample (mean ± SD; n = 3) production. Cyclic AMP assay buffer  47.1 ± 11.7 0 only 3 ng/mL TSH 152.0 ± 28.2 −ve 5B3^(a) IgG 100 μg/mL 44.5 ± 5.2 5.3 5B3^(a) IgG 10 μg/mL 45.4 ± 6.3 3.4 5B3^(a) IgG 1 μg/mL  52.0 ± 12.1 −ve 9D33 IgG 100 μg/mL 74.2 ± 7.2 −ve 9D33 IgG 10 μg/mL 56.5 ± 4.0 −ve 9D33 IgG 1 μg/mL 65.8 ± 9.8 −ve 9D33 IgG 0.1 μg/mL  61.7 ± 13.3 −ve 9D33 IgG 0.01 μg/mL 52.0 ± 5.1 −ve 9D33 IgG 0.001 μg/mL 61.6 ± 3.8 −ve In control CHO cells, not expressing the TSHR, basal cyclic AMP production in the presence of cyclic AMP assay buffer was 1.02 ± 0.06 pmol/mL (mean ± SD; n = 3) and in the presence of 3 ng/mL TSH was 0.74 ± 0.32 pmol/mL (mean ± SD; n = 3). −ve = negative i.e. no inhibition of cyclic AMP production. ^(a)5B3 is a human monoclonal antibody to glutamic acid decarboxylase (GAD) (negative control for 5C9). Experiment 2 Cyclic AMP concentration % Inhibition of basal pmol/mL cyclic AMP Test Sample (mean ± SD; n = 3) production. Cyclic AMP assay buffer  58.0 ± 15.2 0 only 3 ng/mL TSH 156.5 ± 22.2 −ve 5B3^(a) IgG 100 μg/mL 52.7 ± 7.8 9.1 5B3^(a) IgG 10 μg/mL  43.7 ± 10.4 24.7 5B3^(a) IgG 1 μg/mL  55.9 ± 12.2 3.7 5C9 IgG 100 μg/mL 26.2 ± 2.7 54.9 5C9 IgG 10 μg/mL 14.7 ± 1.7 74.6 5C9 IgG 1 μg/mL 16.8 ± 4.2 71.0 5C9 IgG 0.1 μg/mL 31.5 ± 8.8 45.7 5C9 IgG 0.01 μg/mL 36.4 ± 4.5 37.2 5C9 IgG 0.001 μg/mL 51.7 ± 9.8 10.8 In control CHO cells, not expressing the TSHR, basal cyclic AMP production in the presence of cyclic AMP assay buffer was 0.03 pmol/mL (n = 2) and in the presence of 3 ng/mL TSH was 0.40 ± 0.09 pmol/mL. (mean + SD; n = 3). −ve = negative i.e. no inhibition of cyclic AMP production. ^(a)5B3 is a human monoclonal antibody to glutamic acid decarboxylase (GAD) (negative control for 5C9). Experiment 3 Effects of 5C9 Fab and F(ab′) on basal cyclic AMP production in CHO cells expressing wild type TSHR Cyclic AMP concentration % Inhibition of basal Test Sample in cyclic pmol/mL cyclic AMP AMP assay buffer (mean ± SD; n = 3) production Cyclic AMP assay buffer 59.4 ± 8.6 0 only 9D33 IgG 100 μg/mL 67.8 ± 1.0 −ve 9D33 IgG 10 μg/mL 79.4 ± 9.8 −ve 9D33 IgG 1 μg/mL 71.5 ± 8.8 −ve 9D33 IgG 0.1 μg/mL 75.6 ± 8.9 −ve 9D33 IgG 0.01 μg/mL 60.5 ± 7.5 −ve 9D33 IgG 0.001 μg/mL 52.3 ± 6.3 12 5C9 IgG 100 μg/mL 26.2 ± 1.8 56 5C9 IgG 10 μg/mL 24.5 ± 5.8 59 5C9 IgG 1 μg/mL 22.9 ± 2.1 61 5C9 IgG 0.1 μg/mL 59.1 ± 2.6 1 5C9 IgG 0.01 μg/mL 64.3 ± 8.4 −ve 5C9 IgG 0.001 μg/mL 67.3 ± 9.8 −ve 5C9 Fab 100 μg/mL 23.3 ± 2.3 61 5C9 Fab 10 μg/mL 32.1 ± 4.8 46 5C9 Fab 1 μg/mL 36.4 ± 1.5 39 5C9 Fab 0.1 μg/mL 52.8 ± 1.9 11 5C9 Fab 0.01 μg/mL 61.1 ± 2.4 −ve 5C9 Fab 0.001 μg/mL 62.5 ± 7.3 −ve 5C9 F(ab′) 100 μg/mL 30.9 ± 2.6 48 5C9 F(ab′) 10 μg/mL 36.5 ± 3.4 39 5C9 F(ab′) 1 μg/mL 45.9 ± 4.5 23 5C9 F(ab′) 0.1 μg/mL 48.2 ± 3.1 19 5C9 F(ab′) 0.01 μg/mL 62.3 ± 5.7 −ve 5C9 F(ab′) 0.001 μg/mL 57.9 ± 9.1 3 In control CHO cells, not expressing the TSHR, basal cyclic AMP production in the presence of cyclic AMP assay buffer was 0.03 pmol/mL (n = 2) and in the presence of 3 ng/mL TSH was 0.40 ± 0.09 pmol/mL (mean ± SD; n = 3). −ve = negative i.e. no inhibition of cyclic AMP production. F(ab′) prepared by reduction of F(ab′)₂; see text for details.

TABLE 15 Effect of patient sera TSHR autoantibodies with antagonist activity (B2-B5) on basal cyclic AMP in levels in CHO cells expressing the TSHR I568T activating mutation Experiment 1 Cyclic AMP concentration Test Sample and serum pmol/mL % Inhibition of basal dilution (mean ± SD; n = 3) cyclic AMP production. Cyclic AMP assay buffer 20.5 ± 8.7 0 only HBD pool/10 19.5 ± 3.4 5 HBD pool/50 25.7 ± 2.8 −ve N1/10 20.7 ± 5.5 −ve N1/50 18.5 ± 1.5 10 N2/10 23.3 ± 1.7 −ve N2/50 17.6 ± 1.8 14 N3/10 20.3 ± 2.4 1 N3/50 23.6 ± 5.9 −ve B2/10  5.3 ± 1.3 74 B2/50  9.6 ± 2.8 53 B3/10  8.3 ± 3.1 60 B3/50 10.5 ± 2.5 49 B4/10  2.2 ± 0.5 89 B4/50  3.0 ± 0.3 86 B5/10 15.9 ± 3.3 23 B5/50 14.5 ± 1.3 29 Experiment 2 Cyclic AMP concentration Test Sample and serum pmol/mL % Inhibition of basal dilution (mean ± SD; n = 3) cyclic AMP stimulation Cyclic AMP assay buffer 19.7 ± 3.7 0 only HBD pool/10 28.0 ± 1.6 −ve HBD pool/50 18.1 ± 3.9 8 HBD pool/100 18.0 ± 1.6 9 HBD pool/500 17.8 ± 1.3 10 HBD pool/1000 20.7 ± 2.9 −ve HBD pool/5000 15.6 ± 2.1 20 B3/10 14.7 ± 2.2 25 B3/50 13.7 ± 1.3 31 B3/100 12.6 ± 0.6 36 B3/500 19.0 ± 0.8 4 B3/1000 18.4 ± 4.6 7 B3/5000 17.6 ± 0.9 11 B4/10  4.0 ± 0.5 80 B4/50  3.6 ± 0.8 81 B4/100  3.8 ± 1.1 81 B4/500  7.2 ± 2.6 64 B4/1000 12.0 ± 0.6 39 B4/5000 17.7 ± 2.7 10 −ve = negative i.e. no inhibition of cyclic AMP production. HBD pool = pool of healthy blood donor sera N1-N3 = individual healthy blood donor sera All sera were diluted in cyclic AMP assay buffer.

TABLE 16 Effect of patient sera TSHR autoantibodies with antagonist activity (B2-B5) on basal cyclic AMP levels in CHO cells expressing the TSHR S281I activating mutation Cyclic AMP concentration % Inhibition of basal Test Sample and serum pmol/mL (mean ± SD; cyclic AMP dilution n = 3) production Cyclic AMP assay buffer 11.2 ± 2.0  0 only HBD/10 12.1 ± 0.6  −8 HBD/50 10.0 ± 2.0  11 N1/10 8.0 ± 1.6 28 N1/50 10.8 ± 3.3  4 N2/10 8.8 ± 1.4 21 N2/50 8.8 ± 2.3 22 N3/10 10.0 ± 0.8  17 N3/50 9.3 ± 1.7 17 B2/10  7.7 ± 039 31 B2/50 5.7 ± 1.3 49 B3/10 5.4 ± 0.5 52 B3/50 6.6 ± 1.1 41 B4/10 5.4 ± 1.1 52 B4/50 4.9 ± 0.7 56 B5/10 9.1 ± 2.5 18 B5/50 7.6 ± 0.8 32 See Table 15 for explanatory footnotes. 5C9 IgG at 1 μg/mL caused 71% inhibition of basal cyclic AMP activity in the experiments with TSHR S281I.

TABLE 17 Effect of patient sera TSHR autoantibodies with antagonist activity (B2-B5) on basal cyclic AMP levels in CHO cells expressing the TSHR A623I activating mutation Cyclic AMP concentration % Inhibition of basal Test Sample and serum pmol/mL (mean ± SD; cyclic AMP dilution n = 3) production Cyclic AMP assay buffer  43.5 ± 11.2 0 only HBD pool/10 34.7 ± 4.5 20 HBD pool/50 49.9 ± 5.7 −15 N1/10 32.1 ± 2.5 26 N1/50  43.9 ± 12.0 −1 N2/10 51.1 ± 8.4 −17 N2/50 32.6 ± 2.1 26 N3/10 47.2 ± 7.1 −10 N3/50  57.3 ± 16.5 −32 B2/10 28.8 ± 1.1 34 B2/50 43.9 ± 2.7 −1 B3/10 33.5 ± 3.5 23 B3/50  44.2 ± 12.7 −1 B4/10 27.2 ± 6.6 37 B4/50 23.9 ± 1.0 45 B5/10 19.2 ± 6.3 56 B5/50  40.6 ± 10.9 7 See Table 15 for explanatory footnotes. 5C9 IgG at 1 μg/mL caused 49% inhibition of basal cyclic AMP activity in experiments with TSHR A623I.

TABLE 18 Effect of patient sera TSHR autoantibodies with antagonist activity (B2-B5) on basal cyclic AMP levels in CHO cell line expressing wild type TSHR (approximately 5 × 10⁵ receptors per cell) Cyclic AMP Change in Test Sample and concentration basal cyclic serum pmol/mL (mean ± SD; AMP dilution n = 3) production (%) Cyclic AMP 28.1 ± 0.7  100 assay buffer only HBD/10 37.5 ± 6.9  133 HBD/50 37.2 ± 2.4  132 N1/10 27.7 ± 5.7  99 N1/50 26.0 ± 4.8  93 N2/10 41.0 ± 2.7  146 N2/50 27.0 ± 1.2  96 N3/10 34.3 ± 2.7  122 N3/50 38.5 ± 7.8  137 B2/10 39.7 ± 1.7  141 B2/50 41.4 ± 3.8  147 B3/10 74.0 ± 11.2 263 B3/50 46.5 ± 8.7  165 B4/10 8.7 ± 0.3 31 B4/50 17.2 ± 1.9  61 B5/10 54.2 ± 6.0  193 B5/50 48.0 ± 10.5 171 Change in basal cyclic AMP production (%) = $\frac{{cyclic}\mspace{14mu}{AMP}\mspace{14mu}{production}\mspace{14mu}{in}\mspace{14mu}{the}\mspace{14mu}{presence}\mspace{14mu}{of}\mspace{14mu}{test}\mspace{14mu}{sample}}{\begin{matrix} {{cyclic}\mspace{14mu}{AMP}\mspace{14mu}{production}\mspace{14mu}{in}\mspace{14mu}{the}\mspace{14mu}{presence}\mspace{20mu}{of}\mspace{14mu}{cyclic}} \\ {{AMP}\mspace{14mu}{buffer}} \end{matrix}} \times 100$ In the presence of 5C9 IgG at 1 μg/mL, basal cyclic AMP levels decreased to 33% relative to levels in the presence of cyclic AMP assay buffer.

TABLE 19 Summary of the effects of patient sera TSHR autoantibodies with antagonist activity (B2-B5) on basal cyclic AMP levels in TSHR transfected CHO cells CHO cells Cyclic AMP concentration (fmol/cell well; mean ±SD, n = 3) in the presence of:- transfected with HBD pool B2 B3 B4 B5 5C9 IgG Wild type TSHR 5531 ± 1140 7949 ± 340 14804 ± 2240 1740 ± 68  10849 ± 1206 1872 ± 288 TSHR I568T 3900 ± 671  1066 ± 266 1660 ± 628 438 ± 90  3180 ± 650 548 ± 78 TSHR A623I 6420 ± 968  5760 ± 224 6700 ± 704 5440 ± 1324  7680 ± 1260 1914 ± 176 TSHR S281I 2420 ± 130  1538 ± 175 1080 ± 96  1080 ± 218  1822 ± 494 655 ± 60 HBD pool = pool of healthy blood donor sera. HBD pool and sera B2-B5 were used at 1:10 dilution in cyclic AMP assay buffer. 5C9 IgG was used at a concentration of 1 μg/mL in cyclic AMP assay buffer. B2-B5 blocked both TSH and M22 stimulation of cyclic AMP production in CHO cells expressing wild type TSHR.

TABLE 20a Effect of 5C9 IgG on pTSH stimulated cyclic AMP production in CHO cells expressing wild type TSHR and TSHR with Asp43 mutated to Alanine. Cyclic AMP produced Mutated/ (fmol/cell well; wild mean ± SD, n = 3) type Test sample Wild type TSHR Mutated TSHR (%) Cyclic AMP assay buffer  277 ± 109 173 ± 81 76 only TSH only 13924 ± 717  11651 ± 465  84 5B3^(a) 10 μg/mL + TSH 14263 ± 2791 17452 ± 2160 122 5B3^(a) 100 μg/mL + TSH 18892 ± 1222 12685¹ 67 5C9 0.01 μg/mL + TSH 13145¹ 12722 ± 695  97 5C9 0.1 μg/mL + TSH 7813 ± 505 6726 ± 488 86 5C9 1.0 μg/mL + TSH 2021 ± 515  471 ± 217 23 5C9 10 μg/mL + TSH  306 ± 287 119 ± 68 39 5C9 100 μg/mL + TSH  84 ± 93   31² 37 5C9 100 μg/mL only  47 ± 23  206 ± 107 438 ¹mean of duplicate determinations ²single determination pTSH concentration = 3 ng/mL All dilutions in cyclic AMP assay buffer ^(a)5B3 is a human monoclonal antibody to glutamic acid decarboxylase (GAD) (negative control for 5C9).

TABLE 20b Effect of 5C9 IgG on pTSH stimulated cyclic AMP production in CHO cells expressing wild type TSHR and TSHR with Glu61 mutated to Alanine. Cyclic AMP produced Mutated/ (fmol/cell well; wild mean ± SD, n = 3) type Test sample Wild type TSHR Mutated TSHR (%) Cyclic AMP assay buffer  210 ± 101 146 ± 22 70 only TSH only 12818 ± 2224 15398 ± 982  120 5B3^(a) 10 μg/mL + TSH 11522 ± 2220 19750 ± 2950 171 5B3^(a) 100 μg/mL + TSH 14090 ± 2394 15680 ± 2708 111 5C9 0.01 μg/mL + TSH 13806 ± 1188 18050 ± 2948 131 5C9 0.1 μg/mL + TSH 2886 ± 422 2114 ± 592 73 5C9 1.0 μg/mL + TSH  536 ± 150  766 ± 354 143 5C9 10 μg/mL + TSH  254 ± 208  346 ± 292 136 5C9 100 μg/mL + TSH  202¹ 328 ± 96 162 5C9 100 μg/mL only 218 ± 46 254 ± 48 117 See Table 20a for explanatory footnotes.

TABLE 20c Effect of 5C9 IgG on pTSH stimulated cyclic AMP production in CHO cells expressing wild type TSHR and TSHR with His105 mutated to Alanine. Cyclic AMP produced Mutated/ (fmol/cell well; wild mean ± SD, n = 3) type Test sample Wild type TSHR Mutated TSHR (%) Cyclic AMP assay buffer 245 ± 98 590 ± 72 241 only TSH only 14214 ± 2111 17979 ± 1735 126 5B3^(a) 10 μg/mL + TSH 13214 ± 3233 21359 ± 1501 162 5B3^(a) 100 μg/mL + TSH 17232 ± 2641 24044 ± 3398 140 5C9 0.01 μg/mL + TSH 16652 ± 2252 24168 ± 1690 145 5C9 0.1 μg/mL + TSH 3511 ± 590  2869 ± 1460 82 5C9 1.0 μg/mL + TSH 454 ± 11  561 ± 393 124 5C9 10 μg/mL + TSH 289 ± 84  434 ± 392 150 5C9 100 μg/mL + TSH 223¹ 134¹ 60 5C9 100 μg/mL only 234 ± 50  520 ± 198 222 See Table 20a for explanatory footnotes.

TABLE 20d Effect of 5C9 IgG on pTSH stimulated cyclic AMP production in CHO cells expressing wild type TSHR and TSHR with Glu107 mutated to Alanine. Cyclic AMP produced Mutated/ mol/cell well; mean ± SD, n = 3) wild type Test sample Wild type TSHR Mutated TSHR (%) Experiment 1 Cyclic AMP assay buffer  326 ± 157 1898 ± 594 582 only TSH only 14838 ± 1396 13435 ± 2613 91 5B3^(a) 10 μg/mL + TSH 14018 ± 3049 17074 ± 1442 122 5B3^(a) 100 μg/mL + TSH 15949 ± 1340 16009 ± 4606 100 5C9 0.01 μg/mL + TSH 17001 ± 5209 15008 ± 1053 88 5C9 0.1 μg/mL + TSH 5950¹  5783 ± 3213 97 5C9 1.0 μg/mL + TSH 1058 ± 396  394 ± 314 37 5C9 10 μg/mL + TSH 496 ± 52  449 ± 116 91 5C9 100 μg/mL + TSH  193 ± 196 203 ± 56 105 5C9 100 μg/mL only 1266 ± 359  462 ± 324 36 Experiment 2 Cyclic AMP assay buffer  167 ± 148 1824 ± 354 1092 only TSH only 17569 ± 3919 19358 ± 2365 110 5B3^(a) 10 μg/mL + TSH 11692 ± 1161 21255 ± 2597 182 5B3^(a) 100 μg/mL + TSH 24141 ± 1869 22933 ± 6554 95 5C9 0.01 μg/mL + TSH 18585 ± 5353 21028 ± 1432 113 5C9 0.1 μg/mL + TSH  4221 ± 1003 1544 ± 732 37 5C9 1.0 μg/mL + TSH 738 ± 48 28¹ 4 5C9 10 μg/mL + TSH  214 ± 343  321 ± 514 150 5C9 100 μg/mL + TSH  238¹ 64² 27 5C9 100 μg/mL only 211 ± 75  408 ± 138 193 See Table 20a for explanatory footnotes.

TABLE 20e Effect of 5C9 IgG on pTSH stimulated cyclic AMP production in CHO cells expressing wild type TSHR and TSHR with Phe130 mutated to Alanine. Cyclic AMP produced Mutated/ (fmol/cell well; mean ± SD, n = 3) wild type Test sample Wild type TSHR Mutated TSHR (%) Cyclic AMP assay buffer  345 ± 119 410 ± 85 119 only TSH only 15897 ± 1291 16392 ± 1318 103 5B3^(a) 10 μg/mL + TSH 18414 ± 1662 15765 ± 1088 86 5B3^(a) 100 μg/mL + TSH 19561 ± 1078 21673 ± 3165 111 5C9 0.01 μg/mL + TSH 15255 ± 2166 17414 ± 1020 114 5C9 0.1 μg/mL + TSH 2712 ± 462  9015 ± 1835 332 5C9 1.0 μg/mL + TSH  398 ± 378  2235 ± 1635 562 5C9 10 μg/mL + TSH  151 ± 195 1139 ± 146 754 5C9 100 μg/mL + TSH  240 ± 199  603 ± 141 251 5C9 100 μg/mL only 334 ± 75 446 ± 41 134 See Table 20a for explanatory footnotes.

TABLE 20f Effect of 5C9 IgG on pTSH stimulated cyclic AMP production in CHO cells expressing wild type TSHR and TSHR with Glu178 mutated to Alanine. Cyclic AMP produced Mutated/ (fmol/cell well; mean ± SD, n = 3) wild type Test sample Wild type TSHR Mutated TSHR (%) Cyclic AMP assay buffer 183 ± 77  366 ± 300 200 only TSH only 8900 ± 1185 7666 ± 1659 86 5B3^(a) 10 μg/mL + TSH 9160 ± 3180 10828 ± 1650  118 5B3^(a) 100 μg/mL + TSH 12920 ± 1300  9428 ± 1350 73 5C9 0.01 μg/mL + TSH 12580 ± 2700  8166 ± 195  65 5C9 0.1 μg/mL + TSH 4354 ± 920  7314 ± 1830 168 5C9 1.0 μg/mL + TSH 688 ± 140 3570 ± 850  519 5C9 10 μg/mL + TSH 630 ± 140 1904 ± 360  302 5C9 100 μg/mL + TSH 712¹ 894 ± 120 126 5C9 100 μg/mL only 196 ± 58  134 ± 153 68 See Table 20a for explanatory footnotes.

TABLE 20g Effect of 5C9 IgG on pTSH stimulated cyclic AMP production in CHO cells expressing wild type TSHR and TSHR with Tyr185 mutated to Alanine. Cyclic AMP produced Mutated/ (fmol/cell well; mean ± SD, n = 3) wild type Test sample Wild type TSHR Mutated TSHR (%) Cyclic AMP assay buffer 139 ± 40 163 ± 72 117 only TSH only 12649 ± 1577 8305 ± 870 66 5B3^(a) 10 μg/mL + TSH 16974 ± 205  10088 ± 1856 59 5B3^(a) 100 μg/mL + TSH 17089 ± 2282 10920 ± 2111 64 5C9 0.01 μg/mL + TSH 17264 ± 4257  9368 ± 2069 54 5C9 0.1 μg/mL + TSH  6217 ± 2064 4536 ± 724 73 5C9 1.0 μg/mL + TSH 1664 ± 636  1199 ± 1042 72 5C9 10 μg/mL + TSH  481 ± 380  301 ± 199 63 5C9 100 μg/mL + TSH  275 ± 206 UD 5C9 100 μg/mL only 123 ± 38 163 ± 60 133 UD = below assay detection limit. See Table 20a for other explanatory footnotes.

TABLE 20h Effect of 5C9 IgG on pTSH stimulated cyclic AMP production in CHO cells expressing wild type TSHR and TSHR with Asp203 mutated to Alanine. Cyclic AMP produced Mutated/ (fmol/cell well; mean ± SD, n = 3) wild type Test sample Wild type TSHR Mutated TSHR (%) Cyclic AMP assay buffer  298 ± 164  742 ± 122 249 only TSH only 11770 ± 398  12594 ± 400  107 5B3^(a) 10 μg/mL + TSH 13266 ± 1105 12232 ± 1819 92 5B3^(a) 100 μg/mL + TSH 14125 ± 704  13006 ± 2452 92 5C9 0.01 μg/mL + TSH 15454 ± 422  14651 ± 511  95 5C9 0.1 μg/mL + TSH 4445 ± 405 13142 ± 1589 296 5C9 1.0 μg/mL + TSH 1352 ± 249 14678 ± 6312 1086 5C9 10 μg/mL + TSH  807 ± 479 12634 ± 1036 1566 5C9 100 μg/mL + TSH 367 ± 67 12721 ± 3187 3446 5C9 100 μg/mL only 330 ± 46 1368 ± 206 415 See Table 20a for explanatory footnotes.

TABLE 20i Effect of 5C9 IgG on pTSH stimulated cyclic AMP production in CHO cells expressing wild type TSHR and TSHR with Tyr206 mutated to Alanine. Cyclic AMP produced Mutated/ (fmol/cell well; mean ± SD, n = 3) wild type Test sample Wild type TSHR Mutated TSHR (%) Cyclic AMP assay buffer  380 ± 166 402 ± 96 106 only TSH only 15360 ± 670  18440 ± 1390 120 5B3^(a) 10 μg/mL + TSH 15880 ± 1150 21000 ± 2340 132 5B3^(a) 100 μg/mL + TSH 19100 ± 3090 19680 ± 3200 103 5C9 0.01 μg/mL + TSH 16100 ± 2360 18420 ± 670  114 5C9 0.1 μg/mL + TSH  6220 ± 1500 10820 ± 1750 174 5C9 1.0 μg/mL + TSH 1306 ± 123 3460 ± 360 265 5C9 10 μg/mL + TSH  396 ± 158 1564 ± 176 395 5C9 100 μg/mL + TSH  292 ± 130  506 ± 120 173 5C9 100 μg/mL only 444 ± 98  482 ± 286 109 See Table 20a for explanatory footnotes.

TABLE 20j Effect of 5C9 IgG on pTSH stimulated cyclic AMP production in CHO cells expressing wild type TSHR and TSHR with Lys209 mutated to Alanine. Cyclic AMP produced Mutated/ (fmol/cell well; mean ± SD, n = 3) wild type Test sample Wild type TSHR Mutated TSHR (%) Cyclic AMP assay buffer 316 ± 38 288 ± 80  91 only TSH only 14200 ± 1420 9500 ± 1620 67 5B3^(a) 10 μg/mL + TSH 12280 ± 610  11200 ± 3000  91 5B3^(a) 100 μg/mL + TSH 16000 ± 1470 13240 ± 1530  83 5C9 0.01 μg/mL + TSH 15440 ± 2180 5960 ± 950  39 5C9 0.1 μg/mL + TSH 4700 ± 339 278 ± 40  6 5C9 1.0 μg/mL + TSH 1184 ± 59  360 ± 146 30 5C9 10 μg/mL + TSH  984 ± 117 482 ± 100 49 5C9 100 μg/mL + TSH  602 ± 240 354 ± 184 59 5C9 100 μg/mL only 272 ± 49 280 ± 104 103 See Table 20a for explanatory footnotes.

TABLE 20k Effect of 5C9 IgG on TSH stimulated cyclic AMP production in CHO cells expressing wild type TSHR and TSHR with Asp232 mutated to Alanine. Cyclic AMP produced Mutated/ (fmol/cell well; mean ± SD, n = 3) wild type Test sample Wild type TSHR Mutated TSHR (%) Cyclic AMP assay buffer 650 ± 87  652 ± 300 100 only TSH only 15681 ± 866  14884 ± 1587 95 5B3^(a) 10 μg/mL + TSH 15210 ± 1697 17800 ± 3219 117 5B3^(a) 100 μg/mL + TSH 19704 ± 1173 17478 ± 3150 89 5C9 0.01 μg/mL + TSH 17600 ± 1347 15330 ± 1593 87 5C9 0.1 μg/mL + TSH 7329 ± 860  6556 ± 1668 89 5C9 1.0 μg/mL + TSH 1072 ± 705 1882 ± 653 176 5C9 10 μg/mL + TSH  794 ± 406  710 ± 596 89 5C9 100 μg/mL + TSH 166 ± 95  55 ± 51 33 5C9 100 μg/mL only 522 ± 84 99¹ 19 See Table 20a for explanatory footnotes.

TABLE 20l Effect of 5C9 IgG on pTSH stimulated cyclic AMP production in CHO cells expressing wild type TSHR and TSHR with Lys250 mutated to Alanine. Cyclic AMP produced Mutated/ (fmol/cell well; mean ± SD, n = 3) wild type Test sample Wild type TSHR Mutated TSHR (%) Cyclic AMP assay buffer 590 ± 86 1020 ± 104 173 only TSH only 13332 ± 1177 10933 ± 1510 82 5B3^(a) 10 μg/mL + TSH 11292 ± 1784 13410 ± 2930 119 5B3^(a) 100 μg/mL + TSH 14236 ± 3521 14049 ± 3372 99 5C9 0.01 μg/mL + TSH 15191 ± 4117 14460 ± 2690 95 5C9 0.1 μg/mL + TSH  6295 ± 1897  8486 ± 2961 135 5C9 1.0 μg/mL + TSH  643 ± 207 2567 ± 841 399 5C9 10 μg/mL + TSH  286 ± 116  862 ± 398 301 5C9 100 μg/mL + TSH  158 ± 244  96 ± 57 61 5C9 100 μg/mL only 458 ± 94  448 ± 280 98 See Table 20a for explanatory footnotes.

TABLE 20m Effect of 5C9 IgG on pTSH stimulated cyclic AMP production in CHO cells expressing wild type TSHR and TSHR with Glu251 mutated to Alanine. Cyclic AMP produced Mutated/ (fmol/cell well; mean ± SD, n = 3) wild type Test sample Wild type TSHR Mutated TSHR (%) Cyclic AMP assay buffer 380 ± 84   960 ± 372 253 only TSH only 18379 ± 987  17492 ± 1332 95 5B3^(a) 10 μg/mL + TSH 15152 ± 4365  19951 ± 2362 132 5B3^(a) 100 μg/mL + TSH 18169 ± 3454  20461 ± 1345 113 5C9 0.01 μg/mL + TSH 21197 ± 1280  21950 ± 936  104 5C9 0.1 μg/mL + TSH 8640 ± 2123 15532 ± 2571 180 5C9 1.0 μg/mL + TSH 915 ± 139 5240 ± 332 573 5C9 10 μg/mL + TSH 752 ± 127 1881 ± 212 250 5C9 100 μg/mL + TSH 496 ± 166 1170 ± 123 236 5C9 100 μg/mL only 460 ± 102  406 ± 212 88 See Table 20a for explanatory footnotes.

TABLE 20n Effect of 5C9 IgG on pTSH stimulated cyclic AMP production in CHO cells expressing wild type TSHR and TSHR with Thr257 mutated to Alanine. Cyclic AMP produced Mutated/ (fmol/cell well; mean ± SD, n = 3) wild type Test sample Wild type TSHR Mutated TSHR (%) Cyclic AMP assay buffer  626 ± 153 1140 ± 153 182 only TSH only 16928 ± 2079 18563 ± 1573 110 5B3^(a) 10 μg/mL + TSH 17542 ± 1874 23341 ± 4203 133 5B3^(a) 100 μg/mL + TSH 18948 ± 1444 20101 ± 2902 106 5C9 0.01 μg/mL + TSH 18722 ± 3876 21088 ± 1810 113 5C9 0.1 μg/mL + TSH  6143 ± 1233  7944 ± 1138 129 5C9 1.0 μg/mL + TSH 1396 ± 172 1594 ± 156 114 5C9 10 μg/mL + TSH 638 ± 58 972 ± 12 152 5C9 100 μg/mL + TSH 591 ± 99 611 ± 52 103 5C9 100 μg/mL only  566 ± 143  637 ± 300 111 See Table 20a for explanatory footnotes.

TABLE 20o Effect of 5C9 IgG on pTSH stimulated cyclic AMP production in CHO cells expressing wild type TSHR and TSHR with Arg274 mutated to Alanine. Cyclic AMP produced Mutated/ (fmol/cell well; mean ± SD, n = 3) wild type Test sample Wild type TSHR Mutated TSHR (%) Cyclic AMP assay buffer 124 ± 103 86 ± 38 69 only TSH only 21347 ± 1112  11432 ± 2511  54 5B3^(a) 10 μg/mL + TSH 18654 ± 3700  12961 ± 2609  69 5B3^(a) 100 μg/mL + TSH 26203 ± 4753  13138 ± 2248  50 5C9 0.01 μg/mL + TSH 16345 ± 3974  9557 ± 2479 58 5C9 0.1 μg/mL + TSH 4997 ± 1392 1320 ± 158  26 5C9 1.0 μg/mL + TSH 808 ± 510 177 ± 120 22 5C9 10 μg/mL + TSH 684 ± 182 108¹ 16 5C9 100 μg/mL + TSH 246 ± 165  17² 7 5C9 100 μg/mL only 111 ± 26  34 ± 43 31 See Table 20a for explanatory footnotes.

TABLE 20p Effect of 5C9 IgG on pTSH stimulated cyclic AMP production in CHO cells expressing wild type TSHR and TSHR with Asp276 mutated to Alanine. Cyclic AMP produced Mutated/ (fmol/cell well; mean ± SD, n = 3) wild type Test sample Wild type TSHR Mutated TSHR (%) Experiment 1 Cyclic AMP assay buffer  365 ± 166 1454 ± 258 398 only TSH only 17500 ± 727  22416 ± 2570 128 5B3^(a) 10 μg/mL + TSH 19354 ± 1794 25180 ± 5609 130 5B3^(a) 100 μg/mL + TSH 21671 ± 2064 25707 ± 4101 119 5C9 0.01 μg/mL + TSH 17236 ± 2705 26212 ± 2597 152 5C9 0.1 μg/mL + TSH 5594 ± 723 16856 ± 2110 301 5C9 1.0 μg/mL + TSH 759¹ 4788 ± 553 631 5C9 10 μg/mL + TSH  366 ± 145 1384 ± 602 378 5C9 100 μg/mL + TSH  344 ± 566  565 ± 176 164 5C9 100 μg/mL only  300 ± 242  602 ± 274 201 Experiment 2 Cyclic AMP assay buffer 156 ± 30  601 ± 190 385 only TSH only 13852 ± 756  14616 ± 453  106 5B3^(a) 10 μg/mL + TSH 13025 ± 3292 17706¹ 136 5B3^(a) 100 μg/mL + TSH 14245 ± 1024 18041 ± 4561 127 5C9 0.01 μg/mL + TSH 14066 ± 2291 21213 ± 3443 151 5C9 0.1 μg/mL + TSH 4462 ± 363  7320 ± 1614 164 5C9 1.0 μg/mL + TSH  657 ± 257 1513 ± 835 230 5C9 10 μg/mL + TSH  541 ± 224 1301 ± 911 240 5C9 100 μg/mL + TSH  286 ± 184 288 ± 87 101 5C9 100 μg/mL only 208 ± 15 314 ± 69 151 See Table 20a for explanatory footnotes.

TABLE 21 Summary of effects of TSHR mutations (relative to wild type) on the ability of 5C9 IgG and 9D33 IgG to block TSH stimulation of cyclic AMP production in TSHR transfected CHO cells Stimulation Blocking (relative Blocking (relative (relative to to wild type) of to wild type) of wild type) TSH stimulation TSH stimulation of cyclic AMP of cyclic of cyclic production AMP production AMP production TSHR Mutation by pTSH by 5C9 IgG by 9D33 IgG Wild type +++++ +++++ +++++ Asp 43 Ala +++ +++++ +++++ Lys 58 Ala +++++ +++++ 0 Ile 60 Ala +++++ +++++ +++++ Glu 61 Ala ++++ +++++ +++++ Arg 80 Ala +++++ +++++ 0 Tyr 82 Ala +++++ +++++ 0 Thr 104 Ala +++++ +++++ NT His 105 Ala +++++ +++++ NT Glu 107 Ala +++ +++++ +++++ Arg 109 Ala +++++ +++++ 0 Lys 129 Ala +++++ 0 0 Phe 130 Ala +++++ +++ +++++ Phe 134 Ala +++++ +++++ ++ Asp 151 Ala +++++ ++++ NT Glu 178 Ala ++++ +++ ++++ Lys 183 Ala +++++ + +++++ Tyr 185 Ala ++++ +++++ +++++ Asp 203 Ala ++++ 0 +++++ Tyr 206 Ala ++++ +++ +++++ Lys 209 Ala ++++ +++++++ +++++ Asp 232 Ala +++ +++++ +++++ Gln 235 Ala +++++ +++++ +++++ Lys 250 Ala +++++ ++++ ++++ Glu 251 Ala +++++ +++ +++++ Arg 255 Ala +++++ +++++ +++++ Thr 257 Ala +++++ +++++ +++++ Trp 258 Ala +++++ +++++ +++++ Arg 274 Ala +++++ +++++++ +++++++ Asp 276 Ala +++++ ++++ +++++ Ser 281 Ala ++++ +++++ ++++ Arg 80 Asp ++++ +++++ 0 Asp 151 Arg +++++ +++++ NT Lys 183 Asp +++ + +++++ Arg 255 Asp +++++ +++++ +++++++ Asp 160 Lys 0 +++++^(a) NT pTSH concentration used = 3 ng/mL. Relative effects of TSHR mutations were expressed as a percentage of activity observed with wild type as follows:- +++++ = 100% wild type activity; ++++ = <100-80% of wild type activity; +++ = <80-60% of wild type activity; ++ = <60-40% of wild type activity; + = <40-20% of wild type activity; 0 = <20% of wild type activity, and increased activity relative to wild type: >100% = +++++++. NT = not tested. ^(a)Stimulation of cyclic AMP for this experiment was tested using M22 due to lack of response to TSH (see text for details)

TABLE 22 Effect of TSHR Asp203Ala mutation on the ability of patient sera TSHR autoantibodies with antagonist activity (B2-B5) to block TSH stimulation of cyclic AMP production Wild type Wild type TSHR TSHR TSHR cyclic TSHR Asp203Ala Asp203Ala Test Sample AMP % inhibition of cyclic AMP % inhibition of and concentration TSH stimulated concentration TSH stimulated serum fmol/cell well. cyclic AMP fmol/cell well. cyclic AMP dilution^(a) Mean ± SD; n = 3 level^(b) Mean ± SD; n = 3 level^(b) Cyclic AMP 242 ± 130 292 ± 89  assay buffer TSH^(c) 9357 ± 1155 7591 ± 832  TSH^(c) + 1 μg/mL 1110 ± 811  92 9400¹  4 5C9 HBD pool/10 183 ± 67  496 ± 76  TSH^(c) + HBD 13303 ± 1819   0 9756¹  0 pool/10 B2/10 110 ± 36  270 ± 72  TSH^(c) + B2/10 454 ± 381 97 1963 ± 357  80 B3/10 329¹ 582 ± 74  TSH^(c) + B3/10 3407 ± 1341 74 4027 ± 278  59 B4/10 59 ± 22 161 ± 36  TSH^(c) + B4/10 278 ± 73  98 150 ± 41  98 B5/10 647 ± 170 1064 ± 228  TSH^(c) + B5/10 4173 ± 515  69 6871 ± 618  30 ^(a)Dilution in cyclic AMP assay buffer. ^(b)% Inhibition of TSH induced cyclic AMP stimulation $100 \times \left( {1 - \frac{\mspace{14mu}\begin{matrix} {{cyclic}\mspace{14mu}{AMP}\mspace{14mu}{produced}\mspace{14mu}{in}\mspace{14mu}{the}\mspace{14mu}{presence}} \\ {{of}\mspace{14mu}{test}\mspace{14mu}{{sample}/10}\mspace{14mu}{and}\mspace{14mu}{TSH}\mspace{14mu}\left( {3\mspace{14mu}{ng}\text{/}{mL}} \right)} \end{matrix}}{\mspace{14mu}\begin{matrix} {{cyclic}\mspace{14mu}{AMP}\mspace{14mu}{produced}\mspace{14mu}{in}\mspace{14mu}{the}\mspace{14mu}{presence}} \\ {{{of}/10}\mspace{14mu}{HBD}\mspace{14mu}{pool}\mspace{14mu}{and}\mspace{14mu}{TSH}\mspace{14mu}\left( {3\mspace{14mu}{ng}\text{/}{mL}} \right)} \end{matrix}}} \right)$ ¹mean of duplicate samples ^(c)pTSH used at a final concentration of 3 ng/mL HBD pool = pool of healthy blood donor sera. 

The invention claimed is:
 1. An isolated human monoclonal or recombinant antibody for the Thyroid Stimulating Hormone Receptor (TSHR), wherein said antibody is an antagonist of Thyroid Stimulating Hormone (TSH), and has a binding affinity for full length human TSHR of about 10⁹ L/mol, and wherein said antibody comprises a V_(H) region comprises the following Complement Determining Regions (CDRs): a) SNYMS (CDR1) (SEQ ID NO: 1); b) VTYSGGSTSYADSVKG (CDR2) (SEQ ID NO: 2); and c) GGRYCSSISCYARSGCDY (CDR3) (SEQ ID NO: 3);

and said antibody comprises a V_(L) region comprises the following CDRs: a) RASQSISNYLN (CDR1) (SEQ ID NO: 4); b) AASSLQS (CDR2) (SEQ ID NO: 5); and c) QQSYSSPSTT (CDR3) (SEQ ID NO: 6).


2. The antibody according to claim 1, wherein said antibody is an antagonist of thyroid stimulating antibodies.
 3. The antibody according to claim 1, wherein said antibody has TSH antagonist characteristics of patient serum TSHR autoantibodies which are TSH antagonists.
 4. The antibody according to claim 1, wherein said antibody has the antagonistic characteristics of patient serum TSHR autoantibodies which are antagonists of thyroid stimulating antibodies.
 5. The antibody according to claim 1, wherein said antibody is an inhibitor of binding to TSHR or a portion thereof by TSH, by M22, by antibodies with stimulating activity or antibodies with blocking activity to the TSHR.
 6. The antibody according to claim 5, wherein the TSHR portion includes the Leucine Rich Domain (LRD) of TSHR or a substantial portion thereof.
 7. The antibody according to claim 1, wherein said antibody comprises or consists of an antigen-binding fragment thereof.
 8. The antibody according to claim 1, wherein said antibody has a binding affinity for human full length TSHR of about 10¹⁰ L/mol.
 9. A composition comprising the antibody according to claim
 1. 10. A pharmaceutical composition comprising the antibody according to claim 1 and a pharmaceutically acceptable carrier.
 11. The pharmaceutical composition according to claim 10, wherein the composition comprises thyroid stimulating hormone receptor antagonist 9D33.
 12. The antibody according to claim 1, wherein said antibody inhibits TSHR constitutive activity.
 13. An isolated humanised monoclonal or recombinant antibody for the TSHR, wherein said antibody is an antagonist of TSH and has a binding affinity for full length human TSHR of about 10⁹ L/mol, and wherein said antibody comprises a V_(H) region comprises of the following Complement Determining Regions (CDRs): a) SNYMS (CDR1) (SEQ ID NO: 1); b) VTYSGGSTSYADSVKG (CDR2) (SEQ ID NO: 2); and c) GGRYCSSISCYARSGCDY (CDR3) (SEQ ID NO: 3);

and said antibody comprises a V_(L) region comprises of the following CDRs: a) RASQSISNYLN (CDR1) (SEQ ID NO: 4); b) AASSLQS (CDR2) (SEQ ID NO: 5); and c) QQSYSSPSTT (CDR3) (SEQ ID NO: 6). 